Burn Management all Phases

PRE-HOSPITAL BURN MANAGEMENT

1. Small thermal (<10% TBSA) - cool, clean, damp towel

2. Large thermal
ABCs
- airway patency, soot around nares, singed hair
- breathing adequacy
- pulse presence, regularity

3. Chemical
remove chemical (brush off)
lavage; blot dry
remove clothes
clean sheet

4. Electrical
remove from source
ABCs
C-spine precautions
exit/entry site
distal pulses
assess for injury (d/t falls, muscle contractions)
dry, clean sheet

EMERGENT PHASE

Phase during which immediate problems are addressed/resolved

Fluid loss/edema formation until fluid mobilization/diuresis

Pathophysiologic Problems

Fluid and electrolyte shifts:

Burn injury >>> increased blood flow >>> release of vasoactive substances >>>
increased capillary permeability >>> water, Na, plasma protein shifts to interstitial and
surrounding tissues >>> decreased intravascular volume >>> hypovolemic shock and
its S&S.

Insensible losses (evaporation) - up to 400 ml/hour

RBCs:
- hemolyze d/t direct injury and circulating factor
- Hct elevated d/t hemoconcentration (r/t fluid loss)
 - Net anemia (evident after fluid replacement)

Electrolytes
- K+ released from injured cells >>> hyperkalemia
- Na >>> interstitial spaces

RX: fluid resuscitation restores capillary normal permeability >>> stpos fluid losses and
edema >>> interstitial fluid returns to vascular space >>> diuresis

Inflammation and Healing

leukocytes/monocytes accumulate
wound repair 6-12 hours after injury

Immunologic Changes: High infection risk d/t:

loss of protective skin barrier

reduced levels immunoglobulins
reduced #/function WBCs

Clinical Manifestations (Emergent Phase)

pain & hypovolemia >>> S/S shock

blisters (partial thickness burns)
edema
adynamic ileus (r/t trauma and K+ shift)
shivering (heat loss, anxiety, pain)
altered mental status (r/t hypoxia -- smoke inhalation; medications)

Complications (Emergent Phase)

CVS
shock, arrythmias
impaired circulation to extremities r/t circumferential burns/edema >>> ischemia,
necrosis, gangrene
RX: Escharotomy (incision through eschar to restore
circulation
Increased blood viscosity >>> sludging

Respiratory
Upper airway burn >>> obstruction >>> asphyxia
Inhalation injury: alveolar damage d/t inhalation of chemical fumes or smoke >>> edema
interferes with oxygenation

Renal
Hypovolemia >>>renal obstruction >>> ARF
Myoglobin (from muscle breakdown) & hemoglobin (RBC breakdown) can occlude renal
tubules >>> ARF. Prevent with fluid replacement and diuretics

Management: Emergent Phase

ABC: intubate before respiratory failure develops; extubate when edema resolves.
Escharotomy may be performed
Circulation:
- IV access
- Fluid replacement if > 20% TBSA with crystalloids
- Parkland Formula
- Second 24 hours: Colloids

Goal:
- U/O 30-50 ml/hr
- SBP > 90-100 mm Hg (via arterial line)
- HR < 100/mon
- Alert and oriented

WOUND CARE

Stabilize first
Cleanse and debride
Wound RX methods: Open or closed
Wound closure via graft
- heterograft
- homograft
- autograft
- cultured epithelial graft

PHARMACOLOGICAL MANAGEMENT

Analgesics/sedatives (IV)
Tetanus
Antimicrobials: Topical
- Flamazine, Acticoat, Gentamycin/Garamycin topically,
Bactigras, Porcine

NUTRITIONAL MANAGEMENT

Nasogastric tube for paralytic ileus until bowel sounds

Clear fluids >> progress (high cal/protein)
Hypermetabolic: needs 5000 cal/day

ACUTE PHASE
Time from fluid mobilization/diuresis until burns are completely covered or healed
(Duration: weeks/months)

Edema resolves
Burned areas more evident:
- partial thickness: pink-red, waxy/shiny, painful
- full thickness: dry, waxy white-dark brown, no sensation
Bowel sounds return
Healing begins; necrotic tissue sloughs

Clinical Manifestations:
Eschar separates: debride and graft
Partial thickness: self-healing
Hypo/hypernatremia
Hyper/hypokalemia

Complications (Acute Phase)

Infection
Cardio-pulmonary (as for Emergent Phase)
Neuro: extreme disorientation
Musculoskeletal: high risk for contractures***
GI:
- diarrhea (feedings, antibiotics)
- constipation (narcotics, immobility)
- ileus (sepsis)
- ulcers (stress): prevent with H2 histamine blockers
Endocrine: stress diabetes

Management Acute Phase:

Fluid therapy
Wound care
- Debridement (enzymatic, surgical)
- Excision and grafting: sheet graft, mesh graft
- Cultured epithelial autograft
- Artificial skin

Pain Management
- Partial thickness: excruciating
- Full thickness: no pain, except at margins (partial
thickness)
- Narcotic, psychotrophics
- Adjuncts: relaxation, imagery, etc.

Nutrition: high caloric needs; formula; supplements(po, TPN)

Emotional support (pain, disfigurement, body image, functional capacity, rehab)
 REHABILITATIVE PHASE

Begins when wounds covered with skinor are healed; self-care begins!

Healed skin: pink and flat >>> then raised and hyperemic
New tissue: needs ROM to prevent contractures
Pressure garments to keep scars flat

Complications:
Contractures: keep body parts extended

EMOTIONAL SUPPORT!!!!!