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Cc 14 burns
Critical Care (408)
Loma Linda University
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Role of Skin Depth of Burns Primary Survey body temperature regulation maintain fluid/electrolyte balance protect from infection & injury skin – largest organ sensory contact w/ environment vitamin D activation able to regenerate itself
Superficial – 1st degree only damage the outermost layer of the skin epidermis (sunburn) burn appearance red, pink no blisters & dry PAINFUL usually heals in a few days (2-7 days)
Partial Thickness – 2nd degree damages epidermis and dermis can extend into the dermis deep partial thickness burn burn appearance red some edema, shiny swollen, wet, has blisters VERY PAINFUL usually heals in 2 weeks (7-21 days) deeper it is longer the healing
Full Thickness – 3rd degree affects ALL layers of skin usually feels NO PAIN (burned the sensory nerves) no increase in pain when pressure applied to wound burn appearance (charred) tough & leathery white, brown, black, red, lots of color variation very dry can NOT grow new skin treatment: skin graft & surgical excision of wound
Airway (INTUBATE ASAP BEFORE SWELLING OCCURS) maintain airway & constantly reassess administer supplemental O2 at 100 % intubation to protect airway Inhalation Injury (look in the mouth) suspect inhalation injury if enclosed space fumes, smoke can trap inside stridor, hoarse, or raspy voice carbonaceous sputum singed (slightly burned) facial/ nasal hairs occurs in presence or absence of cutaneous (skin) injury carbon monoxide poisoning major predictor of mortality in burn victims administer oxygen 100% by mask
Classification of Burns depth 1 st degree - superficial 2 nd degree - partial thickness 3 rd degree - full thickness extent in percent of total body surface area (TBSA) rule of 9’s (NOT for 1st degree burns) location patient risk factors type: thermal, chemical, electrical, radiation
Breathing listen to verify breath sounds each lung assess adequacy of rate and depth of respiration burns to chest wall lead to decreased COMPLIANCE = requires higher vent pressures to provide patient w/adequate tidal volumes circumferential full thickness burns of the trunk may impair ventilation & should be closely monitored Escharotomy (eschar – dead tissue extensive burn injury) treatment for circumferential burns can be done bedside or in OR cuts made thru inelastic eschar (mechanical, chem, surg) eschar: piece of dead tissue cast off surface of skin return of blood flow through body part
Burn Injury - Physiology immediate release of catecholamine & other mediators ↑BP (HTN) ↑ HR (tachycardia) vasoconstriction disrupted blood flow increased capillary permeability edema everywhere including lungs pulmonary edema hypovolemia (low blood volume) massive fluid shift ↑HR (tachycardia) low CO decreased perfusion to GI system paralytic ileus abdominal distention stress ulcer inflammatory response destroyed skin immunosuppression risk for infection/sepsis loss of ability to sweat
Circulation burns do NOT bleed assess BP, skin color, peripheral pulses
Skin Graft excision and grafting done in OR on day 1 or day 2
increased demand on the metabolic system massive catabolism & ↑ risk for calories ↑ body temp (hyperthermia) ↑ oxygen demand RBCs hemolyzing hemoconcentration high Hct high Hgb increased blood viscosity risk for clots
complication: bleeding donated skin site will create a new open wound grafts are very fragile auto – health site from pt and placed over burned site for PERMANENT coverage; sites are painful partial/thickness wounds allograft – temporary; better control over bacterial infection than xenograft (from other species)
circumferential wounds to limbs have delayed perfusion distally obtain 2 large bore IV into veins not under burned areas lactated ringers preferred fluid parkland resuscitation formula for first 24hrs Parkland Formula* (4mL lactated ringers) x (kg) x (%TBSA burn) = amount of fluid for first 24hr resuscitation 50% of fluid infused over the first 8 hours 50% of fluid infused over the next 16 hours Risk Factors Increasing Burn Classification
Disability burn patient is typically alert & oriented if patient is not alert & oriented – assess for carbon monoxide poisoning substance abuse hypoxia pre-existing condition (seizure) log roll patient assess for injuries & burns on back identify any gross deformity & serious associated injury
older adults or young children any preexisting cardiovascular, respiratory, or renal disease, diabetes mellitus, peripheral vascular dz alcoholism & drug abuse malnutrition additional injuries besides the burn Types of Burns Thermal (systemic & local edema) flame flash scald contact w/ hot objects Electrical children highest incidence
Chemical acids & alkali organic compounds most common to hands Radiation x-rays oncology based pts uncommon
Exposure/Environmental Control remove all clothing, jewelry, metal, shoes keep warm (d/t lack of thermoregulation) – cover w/ dry sheets, warm blankets, warm environment stop burning process (irrigate w/ cool water) never use ice (d/t vasoconstriction)
Rule of Nines – Extent of Burns* add posterior and anterior sites of body separately do NOT include 1st degree burns when calculating only calculate 2nd and 3rd degree burns
Secondary Survey complete history & physical circumstances surrounding the incident does the injury match the story? EKGs baseline (for all burns) | cardiac monitoring (electrical burns) careful calculation of %TBSA fine tune fluids
Phases of Burn Injury Emergent (resuscitative care) immediately after burn insult secure airway (FIRST hour crucial, as is first 24-36) maintain temperature, remove items (tourniquet)
Cc 14 burns
Course: Critical Care (408)
University: Loma Linda University
