burns

BURNSBURNSBy:By:

IRENE M. MAGBANUA, RNIRENE M. MAGBANUA, RN

Professional Review SpecialistProfessional Review Specialist

ScopeScope

• PreventionPrevention• SafetySafety• Immediate CareImmediate Care• AssessmentAssessment

• Emergency ManagementEmergency Management• 11stst Phase Phase• 22ndnd Phase Phase• 33rdrd Phase Phase• RehabilitationRehabilitation

PREVENTIONPREVENTION

MAJORITY OF BURN CASESMAJORITY OF BURN CASESARE DUE TO NEGLIGENCEARE DUE TO NEGLIGENCESO HAZARD PRECAUTIONSSO HAZARD PRECAUTIONS

MUST BE OBSERVED.MUST BE OBSERVED.

Genius effectGenius effectbka makasunog ka!bka makasunog ka!

““di lang baga pede masunog”di lang baga pede masunog”including your house too!including your house too!

House on FireHouse on Fire

British Capitol in Fire, 1814British Capitol in Fire, 1814

WashingtonWashington inin FlamesFlames, , 18141814

Head InjuryHead Injury

Contusion and ConcussionContusion and Concussion

Spinal Cord InjurySpinal Cord Injury

Spinal CompressionSpinal Compression

FracturesFractures

BleedingBleeding

Inhalation InjuryInhalation Injury

Inhalation InjuryInhalation Injury

INHALATION INJURIESINHALATION INJURIES

Heat Inhalation-Heat Inhalation-HOT AIR OR FLAMESHOT AIR OR FLAMES

Systemic Toxins-Systemic Toxins-ENCLOSED FIRE-CO IS INHALEDENCLOSED FIRE-CO IS INHALED

Smoke Inhalations-Smoke Inhalations-FREQUENTLY HIDDEN BY MORE VISIBLE FREQUENTLY HIDDEN BY MORE VISIBLE INJURIES (60-80% FATALITIES)INJURIES (60-80% FATALITIES)

Indications of inhalation injury Indications of inhalation injury

usually appears within 2-48 hours after the usually appears within 2-48 hours after the burn occurred. Indications may include: burn occurred. Indications may include: • The patient faints The patient faints • Fire or smoke present in a closed area Fire or smoke present in a closed area • Evidence of respiratory distress or upper Evidence of respiratory distress or upper

airway obstruction airway obstruction • Soot around the mouth or nose Soot around the mouth or nose • Nasal hairs, eyebrows, eyelashes have been Nasal hairs, eyebrows, eyelashes have been

singed singed • Burns around the face or neck Burns around the face or neck

““dami ng patay”dami ng patay”

SafetySafety

Don’t panicDon’t panic Drop to the floorDrop to the floor Look for the exitLook for the exit Cover face with wet clothCover face with wet cloth Immerse into cool water or running water Immerse into cool water or running water

immediately if you get burned to prevent immediately if you get burned to prevent further injury.further injury.

Extinguish any remaining fire by dropping Extinguish any remaining fire by dropping and rolling onto the floor. and rolling onto the floor.

ASSESSMENTASSESSMENT

AAIRWAYIRWAYBBREATHINGREATHINGCCIRCULATIONIRCULATIONDDISABILITIESISABILITIESEEXPOSEXPOSE

Expose con’tExpose con’t

A A airwayairway - check nose, face and neck - check nose, face and neck (priority) singed and sooty hair of (priority) singed and sooty hair of the nosethe nose

B B breathing – breathing – rise and fall of chestrise and fall of chestC C circulationcirculation - if there is no breathing - if there is no breathing

and circulation start CPRand circulation start CPRD check for D check for disabilitydisability and manage and manage

accordinglyaccordinglyE E exposeexpose to determine extent of to determine extent of

injuryinjury

Expose con’tExpose con’t

To check other injuriesTo check other injuriesDetermine TBSADetermine TBSARule of Nines “Berker Formula”Rule of Nines “Berker Formula”

Parkland Formula Parkland Formula (4ml x TBSA x BWkg) (4ml x TBSA x BWkg) 1st 8H 1st 8H give ½, give ½, 2nd 8H 2nd 8H give ¼ and for the give ¼ and for the 3rd 8H 3rd 8H give give the last partthe last part

Repeat ABCDE assessmentRepeat ABCDE assessment

Types of BurnsTypes of Burns

Thermal – dry flames, moist and heatThermal – dry flames, moist and heatMechanical – friction or abrasionMechanical – friction or abrasionChemical – acid or alkaliChemical – acid or alkaliElectrical – most fatalElectrical – most fatalRadiation – sunlightRadiation – sunlight

ClassificationsClassifications

1st degree – partial thickness 1st degree – partial thickness painful, no blisters, pink and red, painful, no blisters, pink and red, epidermisepidermis

2nd degree – deep partial thickness 2nd degree – deep partial thickness painless, with blister, (+) blanch and refill painless, with blister, (+) blanch and refill epidermis and dermis epidermis and dermis

3rd degree – full thickness 3rd degree – full thickness painless, leathery, fascia and muscle, F&E painless, leathery, fascia and muscle, F&E imbalanceimbalance

4th degree – bones and visceral organs 4th degree – bones and visceral organs are affected are affected

Layers of SkinLayers of Skin

Extent of InjuryExtent of Injury

Epidermis onlyEpidermis only

All Skin LayersAll Skin Layers

Skin, SQ, Fascia, MusclesSkin, SQ, Fascia, Muscles

11stst Degree Degree

22ndnd Degree Degree

33rdrd Degree Degree

33rdrd degree degreeself-injuryself-injury

33rdrd Degree Degree

44thth Degree Degree

Bones and Bones and visceral organsvisceral organs

are involvedare involved

44thth Degree Degree

Sunburn, 1Sunburn, 1stst degree degree

Thermal InjuryThermal Injury

BlisterBlister

Self-injurySelf-injury

Emergency RoomEmergency Room

ABCDE assessmentABCDE assessmentAirway and fluid resuscitation Airway and fluid resuscitation

(priority)(priority)Give TIG or TAT and TTGive TIG or TAT and TTProphylactic antibioticProphylactic antibioticSterile dressing for wound Sterile dressing for wound

Parkland Formula Parkland Formula

(4ml x TBSA x BWkg) (4ml x TBSA x BWkg)

1st 8H 1st 8H give ½, give ½,

2nd 8H 2nd 8H give ¼ and for the give ¼ and for the

3rd 8H 3rd 8H give give the last partthe last part

TBSATBSA

Entire trunk = A1Entire trunk = A1Both upper extremities = A2Both upper extremities = A2Face = A3Face = A3Entire back = B1Entire back = B1Anterior left upper extremity = B2Anterior left upper extremity = B2Right and left lower extremities = B3Right and left lower extremities = B3

Parkland FormulaParkland Formula

A1+A2+A3 = A4A1+A2+A3 = A4 Total Volume of Infusion = A5Total Volume of Infusion = A5 11stst 8 hours = A6 8 hours = A6 22ndnd 8 hours = A7 8 hours = A7 33rdrd 8 hours = A8 8 hours = A8 B1+B2+B3 = B4B1+B2+B3 = B4 Total Volume of Infusion =B5Total Volume of Infusion =B5 11stst 8 hours = B6 8 hours = B6 22ndnd 8 hours = B7 8 hours = B7 33rdrd 8 hours = B8 8 hours = B8

Questions:Questions:

Most common type of burns = A9Most common type of burns = A9Fatal type of burns = B9Fatal type of burns = B9s/sx of head injury = A10s/sx of head injury = A10s/sx of spinal cord injury = B10s/sx of spinal cord injury = B10

1st Phase 1st Phase Fluid Accumulation Fluid Accumulation

IV to IT and ICIV to IT and IC

most critical periodmost critical period36-48H post burn, FVD or 36-48H post burn, FVD or

hypovolemiahypovolemia3rd fluid shift3rd fluid shiftedema on the injured area (IV to IT) edema on the injured area (IV to IT)

fatal form is circumferential edema fatal form is circumferential edema from chest injuryfrom chest injury

11stst Phase Con’t Phase Con’t

c. edema and p. edema (IV to IC)c. edema and p. edema (IV to IC)hyponatremia (IV to outside from it)hyponatremia (IV to outside from it)hyperkalemia (cell injury) hyperkalemia (cell injury)

11stst Phase Con’t Phase Con’t

urine output to RF (dec. BV)urine output to RF (dec. BV)myoglobinuria destroys the kidney to myoglobinuria destroys the kidney to

RF (muscle destruction) RF (muscle destruction) rhabdomyolysisrhabdomyolysis

BV - BV - TP - TP - H - H - pH – AcidosispH – Acidosis

11stst Phase Con’t Phase Con’t

BV – curling’s ulcer or paralytic ileus BV – curling’s ulcer or paralytic ileus (dec. BV), NPO, NGT lavage, TPN (dec. BV), NPO, NGT lavage, TPN

Infection may set in (isolation)Infection may set in (isolation)

Fluid ResuscitationFluid Resuscitation

May progress to RFMay progress to RF

Blood MonitoringBlood Monitoring

ETT InsertiomETT Insertiom

Pulse Carbon Monoxide Pulse Carbon Monoxide OximetryOximetry

Arrhythmias MonitoringArrhythmias Monitoring

External DefibrillatorExternal Defibrillator

““BECAUSE OF YOU”BECAUSE OF YOU”

2nd Phase 2nd Phase Fluid RemobilizationFluid Remobilization

IT and IC to IVIT and IC to IV

May last 48-60HMay last 48-60HFVE (CHF) FVE (CHF) Hypokalemia Hypokalemia Diuresis phase (oliguria may signifies Diuresis phase (oliguria may signifies

RF)RF)

22ndnd Phase Con’t Phase Con’t

Hyponatremia due to fluid loss from Hyponatremia due to fluid loss from diuresis phasediuresis phase

Infection may set in (isolation)Infection may set in (isolation)Anemia may linger up to recovery Anemia may linger up to recovery

periodperiodComplications from immobility may Complications from immobility may

set in (Circulo-O-electric bed) set in (Circulo-O-electric bed) Anemia may lingerAnemia may linger

““BECAUSE OF YOU”BECAUSE OF YOU”

““pakamatay ka na”pakamatay ka na”

3rd Phase to Recovery Period3rd Phase to Recovery Period

Infection may set in (isolation, Infection may set in (isolation, Sulfadiazine application)Sulfadiazine application)

Healing process to scar formation Healing process to scar formation and contracturesand contractures

Surgery (Reconstructive or Plastic) Surgery (Reconstructive or Plastic) STSG auto-graftSTSG auto-graft

33rdrd Phase Con’t Phase Con’t

Debridement and EscharotomyDebridement and EscharotomyDiet: high caloric high CHONDiet: high caloric high CHONPsychological Aspect: dec. self Psychological Aspect: dec. self

esteem, stigma, perceived body esteem, stigma, perceived body changes, isolation, depression, loss changes, isolation, depression, loss of identity these are all related to of identity these are all related to physical disfigurement.physical disfigurement.

Keloid scar (arm)Keloid scar (arm)

ScarScar

Skin GraftingSkin Grafting

Old Man’s House on FireOld Man’s House on Fire

““pinabayaan ng NANAY”pinabayaan ng NANAY”

ENDEND

Short QuizShort Quiz

1. Fluid accumulation1. Fluid accumulation A. FVEA. FVE2. Fluid remobilization2. Fluid remobilization B. FVDB. FVD3. Hypokalemia3. Hypokalemia C. 1C. 1stst

PhasePhase4. Hyperkalemia4. Hyperkalemia D. 2D. 2ndnd Phase Phase5. Priority during 15. Priority during 1stst phase? phase?

A. fluidA. fluid C. infectionC. infectionB. I&OB. I&O D. all of the aboveD. all of the above

6. diuresis6. diuresis A. 1A. 1stst Phase Phase7. oliguria7. oliguria B. 2B. 2ndnd Phase Phase8. tetany8. tetany9. anemia9. anemia10. infection10. infection11. T wave elevation11. T wave elevation12. T wave inversion 12. T wave inversion

13. STSG?13. STSG?14. type of dressing? (debridement)14. type of dressing? (debridement)15. diet? (recovery)15. diet? (recovery)

END OF QUIZ

Scars shrink and become less noticeable as they age, therefore, immediate surgical revision is delayed until the scar lightens in color, which is usually several months or even a year after a wound has healed.

Massive injuries (such as burns) can cause loss of a large area of skin and may form hypertrophic scars. A hypertrophic scar can cause restricted movement of muscles, joints, and tendons (contracture).

• Surgical repair includes removing excessive scar tissue and a series of small incisions on both sides of the scar site, which creates V-shaped skin flaps (Z-plasty) may be used. The result is a thin, less noticeable scar because the wound closure following a Z-plasty more closely follows the natural skin folds.

•These techniques are planned when a considerable amount of skin has been lost in the original injury, when a thin scar will not heal, and when improved function (rather than aesthetic reasons) are the primary concern. Secondary procedures may later be necessary to achieve appropriate aesthetic results.

• After flushing or soaking the burn for After flushing or soaking the burn for several minutes, cover the burn with several minutes, cover the burn with a sterile non-adhesive bandage or a sterile non-adhesive bandage or clean cloth. clean cloth.

• Protect the burn from friction and Protect the burn from friction and pressure. pressure.

• Over-the-counter pain medications Over-the-counter pain medications may be used to help relieve pain; may be used to help relieve pain; they may also help reduce they may also help reduce inflammation and swelling. inflammation and swelling.

• Minor burns will usually heal without Minor burns will usually heal without further treatment. further treatment.

• If fingers or toes have been burned, If fingers or toes have been burned, separate them with dry sterile, non-separate them with dry sterile, non-adhesive dressings. adhesive dressings.

• Elevate the burned area and protect it Elevate the burned area and protect it from pressure or friction. from pressure or friction.

• Take steps to prevent shock. Lay the Take steps to prevent shock. Lay the victim flat elevate the feet about 12 victim flat elevate the feet about 12 inches, and cover the victim with a coat or inches, and cover the victim with a coat or blanket. DO NOT place the victim in the blanket. DO NOT place the victim in the shock position if a head, neck, back, or leg shock position if a head, neck, back, or leg injury is suspected or if it makes the victim injury is suspected or if it makes the victim uncomfortable. uncomfortable.

• Continue to monitor the victim's vital signs Continue to monitor the victim's vital signs (breathing, pulse, blood pressure). (breathing, pulse, blood pressure).

• DO NOT apply cold compresses and DO NOT apply cold compresses and DO NOT immerse a severe burn in DO NOT immerse a severe burn in cold water. This can cause shock. cold water. This can cause shock.

• DO NOT place a pillow under the DO NOT place a pillow under the victim's head if there is an airway victim's head if there is an airway burn and they are lying down. This burn and they are lying down. This can close the airway. can close the airway.

THANK YOU….