Burns injury

BURNS INJURY

DEFINITION:

Injuries that result from direct contact with a exposure to any thermal, chemical, electrical or radiation source are termed as burns. The resulting effects are influenced by the intensity of the energy, the duration of exposure and the type of tissue damaged.

INCIDENCE OF BURNS INJURY

1. Burn injuries are the third leading cause of accidental death in all age groups


2. Males tend to be injured more frequently than females, except in the elderly population


3. In the United States, two million people seek medical attention every year for injuries caused by burns of these 70,000 are hospitalized with severe injuries

 BURNS INJURY ETIOLOGY:

Burn can be caused from a number of substances or items that come into direct contact with the shin or lungs. Burn injuries are categorized according to the mechanism of injury

• THERMAL BURNS

Exposure to or contact with

• Flame


• Hot liquids


• Semi-solids (e.g.steam)


• Hot objects


• CHEMICAL BURNS

• Organic acids


• Alkalis


• Strong acids


• ELECTRICAL BURNS


• RADIATION BURNS


• Radiation therapy


• INHALATION INJURY

• Asphyxiants (carbon monoxide)

Three degrees of burns

1. First-degree burns are usually limited to redness (erythema), a white plaque and minor pain at the site of injury. These burns involve only the epidermis. Most sunburns can be included as first-degree burns.


2. Second-degree burns manifest as erythema with superficial blistering of the skin, and can involve more or less pain depending on the level of nerve involvement.Second-degree burns involve the superficial (papillary) dermis and may also involve the deep (reticular) dermis layer. Deep dermal burns usually take more than three weeks to heal and should be seen by a surgeon familiar with burn care, as in somecases severe hypertrophic scarring can result. Burns that require more than three weeks to heal are often excised and skin grafted for best result.


3. Third-degree burns occur when the epidermis is lost with damage to the subcutaneous tissue. Burn victims will exhibit charring and extreme damage of the epidermis, and sometimes hard eschar will be present.

 

CLINICAL MANIFESTATIONS:

The incidence, magnitude, and duration of pathophysiologic changes in burns are proportional to the extent of burn injury with a maximal response seen in burns covering 60% or more TBSA

Cardiovascular Response:

• Tachycardia


• Decrease blood pressure


• Hypovolemia


•  Burn Edema:Edema and blister


• Effects On Fluid And Electrolytes And Blood Volume:


• Hyponatremia


• Hypokalemia or hyperkalemia


• Anaemia


• Thrombocytopenia


• Pulmonary Response:

• Hypoxia


• Labored breathing


• Tachypnea


• Erythema or blistering of the oral and pharyngeal mucosa


• Other systemic Responses:


• Renal failure


• Loss of skin


• Hyperthermia or hypothermia


• Paralytic ileus


• Decrease peristalsis


• Decrease bowel sounds


• Gastric Distention


• Gastric bleeding


• Vomiting


• Acidosis

DIAGNOSTIC EVALUATION

•  Chest x-ray


• Serum electrolytes


• CBC


• BUN


• CREATININE


• ABG


• Blood culture and sensitivity


• ECG

MANAGEMENT OF BURN PATIENTS:

Burn management can be classified into three phases:

1. Emergent (resuscitative)


2. Acute phase


3. Rehabilitative phase

EMERGENT PHASE: The emergent or resuscitative phase is the period of time required to resolve the immediate problems resulting from burn injury. This phase may last from onset to 5 or more days, but it usually lasts 24 to 48 hours. This phase begins with fluid loss and oedema formation and continues until fluid mobilization and diuresis

1. Fluid Therapy

• Assess the fluid needs : IV fluid therapy is usually instituted in the patients with burns greater than 20% of TBSA. The type of fluid replacement is determined by size and depth of burn, age of the patient


• Begin IV fluid replacement: Fluid replacement  is accomplished with either crystalloid solutions(physiologic salines, ringer lactate, dextrose 5%, and saline) or colloids (albumin, dextran)

PARKLAND/BAXTER FORMULA:

Lactated Ringer’s Solution: 4ml x kg body weight x % TBSA burned

Day 1: half to be given in first 8 hours and half to be given over next 16 hours

Day2: varies. Colloid is added.

Insert indwelling catheter

• Monitor urine output

1. Wound Care

• Start hydrotherapy or cleansing: In the form of shower  carts, individual showers and bed bath to used to clean the wound

• Debride as necessary: Debris accumulates on the wound surface it can be retard keratinocyte migration thus delaying the epithelialisation process.

Debridement  are 3 types:

1. Natural Debridement: the dead tissue separates from the underlying viable tissue spontaneously.


2. Mechanical Debridement: it involves using surgical scissors and forceps to separate and remove the eschar


3.  Surgical Debridement : it is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to fascia or shaving the burned skin layers gradually down to freely bleeding viable tissue


4. Assess the extent of wound


5. Initiate topical antibiotic therapy:

The three most topical agents are silver sulfadiazine, silver nitrate and mafenate acetate

Administer tetanus toxoid or tetanus antitoxin

ACUTE PHASE:

Fluid Therapy

Replace fluids, depending on the individual patient needs

Administer RBCs if necessary

Wound Care

Assess wound daily

Observe for complications

Continue hydrotherapy

Continue debridement (if necessary)

Early excision and grafting

Provide homografts:

Homografts are skin obtained from living or recently deceased humans. The amniotic membrane  from the human placenta may also be used as a biologic dressing. Heterograft consists skin taken from animals (usually pigs)

Provide Autografts:  It means of covering burn wounds because the graft’s ofthe patient’s own skin and thus are not rejected by the patient’s immune system. Split-thickness autografts can be applied in sheets or in postage stamp like pieces or they can be expanded by meshing so that they can cover 1.5 to 9 times more than a given donor site area

Care of the patients with an autograft

Care of donor site

REHABILITATION PHASE:

• Counsel and teach the patient and family


• Encourage and assist patient in resuming self-care


• Benign physical therapy for maintenance and rehabilitation of motion


• Correct contractures and scarring (surgery, physical therapy or splinting)


• Discuss possible cosmetic or re-constructive surgery

PAIN MANAGEMENT:                              

Pain in the burn patient has been described as a tormenting consequence of burn injury and wound healing. Opioid administration via the intravenous route, particularly in the emergent and acute phase of burn management

• Morphine sulphate remains the analgesic of choice for treatment of acute burn pain.


• Fentanyl is another useful opioid for burn pain


• Patient controlled analgesia (PCA), in which a pump is used to administer a continous infusion of an opioid


• Sustained release opioids such as MS Contin or Oxycodone, have also been used

Anxiolytic medications such as lorazepam and midazolam may also be indicated.

The use of non pharmacology measures has also proven effective management of burn pain.

Measures include relaxation technique, deep breathing exercise, distraction, guided imagery, hypnosis, therapeutic touch, humor, information giving, and music therapy.

 

DIETARY MANAGEMENT:

The most important of these interventions is to provide adequate nutrition and calories to decrease catabolism. Healing of burn wound consumes large quantities of energy.

The total calorie requirement should be 4000-6000 calories per day. Protein requirement ranges from 1.5 to 4 gm of protein per kilogram of body weight every 24 hours.

Lipids are also included in the nutritional support of every burn patient because of their importance of wound healing, cellular integrity and absorption of fat-soluble vitamins. Carbohydrates are also included.

Feeding's are started as soon as possible. If a feeding tube is used, placement into the duodenum is ideal to prevent aspiration.