Burn management
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- 2. Introduction Definition and Causes of burn Degree of burn Percentage of burn Criteria for burn admission Complications of burn First Aid of Burn Management of burn Nursing care plan 2
- 3. Introduction Epidermis Dermis Hypodermis (Fat layer ) 3
- 4. Epidermis Outer layer Prevent most of bacteria, viruses, other foreign substance from entering the body. (when undamaged) Protect the internal organs, muscles, nerves, and blood vessels against trauma. Dermis Inner layer A thick layer of fibrous and elastic tissue that give the skin its flexible and strength. Contain Blood vessels, nerve, hair follicles, sweat and oil glands Hypodermis (Fat layer ) Helps insulate the body from heat and cold Provide protective padding and save energy storage area 4
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- 6. Definition and Cause of Burn Injuries to skin tissues caused by: I. Friction II. Thermal III. Electricity IV. Radiation V. Chemicals VI. Frostbite VII.Inhalation 6
- 7. I. Friction burns Rubbing of the skin Anti-inflammatory creams Rubbing Trauma 7
- 8. II. Thermal burns Flames Hot liquids / objects Gases Flash 8
- 9. III. Electrical burns Accidental electrical contact Depend on: strength of electrical voltage duration of contact 9
- 10. IV. Radiation burns UV light X-rays Radiation therapy Radiant energy Skin effects from ionizing radiation depend on the amount of exposure to the area, with hair loss seen after 3 Gy, redness seen after 10 Gy, wet skin peeling after 20 Gy, and necrosis after 30 Gy. 10
- 11. V. Chemical burns Strong acids (sulfuric acid) Strong bases Detergents Solvents sulfuric acid as found in toilet cleaners, sodium hypochlorite as found in bleach, and halogenated hydrocarbons as found in paint remover Tissue destruction may continue for up to 72 hours after a chemical injury 11
- 12. VI. Frostbite Cold Injury (Frostbite) • Usually affects fingers, toes, nose, and ears • Numbness, pallor, severe pain, swelling, edema • Sensory loss, Handle the tissue carefully! • Skin appear mottled blue, yellowish-white or waxy Interventions – Frostbite Warm rapidly and continuously for 15-20 minutes AVOID slow thawing Do not debrided blisters 12
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- 15. VII. Inhalation Carbon monoxide poisoning (CO) Inhalation of hot air or noxious chemical Signs include singed nares, facial burns, charred lips, posterior pharynx edema, hoarseness, cough, or wheezing Darken oral and nasal membranes Singe: រោល Char : រ្រៀម រលោ ច Pulmonary edema may not appear until 12 to 24 hours after the burn Decrease is surfactant production Decrease in ciliary action 15
- 16. Degree of Burn Every aspect of burn treatment depends on assessment of the depth and extent of burn. i. First degree burn superficial ii. Second degree burn superficial partial thickness iii. Third degree burn deep partial thickness iv. Fourth degree burn Full thickness ,subcutaneous tissue, muscles, bones 16
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- 18. i. First-degree of burns ( Superficial ) Epidermis a portion of the dermis may be injured symptoms Redness Mild pain Dry skin No blisters Mild swelling Involves minimal tissue damage Minimal fluid lose (can dehydration in young child.) Not serious unless large areas involve Generally heals on its own without scarring in 3–5days example – sunburn ,UV light 18
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- 20. ii. Second-degree of burns (Superficial partial thickness) Involves epidermis and part of dermis decreased blood flow in tissue can convert to a full- thickness burn symptoms Blisters Redness, shiny, wet deep redness very painful Spontaneous re-epithelialization in 2–3 weeks Example – contact with hot objects or flame, tar burn 20
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- 22. iii. Third-degree of Burn (deep partial thickness) Epidermis and entire dermis Symptoms Dry skin ,Swelling White, black, brown or yellow skin Little to no pain Requires removal of eschars Can result in disruption of nails, hair, sebaceous glands May cause scarring: skin grafting usually required Example – electrical or chemical sources, flames … 22
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- 24. iv. Fourth-degree of burns (full thickness) Injury involve all layers of the skin and underlying tissue (tendons and bone). Need immediately hospitalization Symptoms Black, white skin No sensation Dry, or hard skin Pain may be intense or absent depending on nerve ending involvement Causes scarring; skin grafting required Example - flames , electrical or chemical sources…etc.24
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- 27. The following factors are considered in determining the depth of the burn: How the injury occurred Causative agent, such as flame or scalding liquid Temperature of the burning agent Duration of contact with the agent Thickness of the skin 27
- 28. Percentage of Burn Various methods are used to estimate the TBSA (total body surface area) affected by burns; among them are: The rule of nines, The Lund and Browder method, and The palm method. 28
- 29. RULE OF NINES An estimation of the TBSA involved in a burn is simplified by using the rule of nines. The rule of nines is a quick way to calculate the extent of burns. The system assigns percentages in multiples of nine to major body surfaces. Note that the ‘ rule of 9s ’ cannot be applied to a child who is less than 14 years old . 29
- 30. Rule of nines 30
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- 32. LUND AND BROWDER METHOD A more precise method of estimating the extent of a burn is the Lund and Browder method, It recognizes that the percentage of TBSA of various anatomic parts, especially the head and legs, and changes with growth. By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by such body parts, one can obtain a reliable estimate of the TBSA burned. The initial evaluation is made on the patient’s arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then. 32
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- 34. Hospital care for children WHO, 34
- 35. PALM METHOD In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of the patient’s palm is approximately 1% of TBSA. (from crease of wrist to the top of extended fingers is approximately 1% of TBSA. 35
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- 37. Fluid Management Fluid resuscitation is required for burns covering: > 15% for adults > 10% for children Use Ringer’s lactate or normal saline with 5% glucose For maintenance fluid use Ringer’s lactate with 5% glucose or half-normal saline with 5% glucose Parkland’s formula is suitable starting Oral supplementation may start 48 hr after as homogenized milk or soy-based products given by bolus or constant infusion via NGT The goal of fluid resuscitation is to anticipate prevent hypovolaemic shock. 37
- 38. Parkland’s formula For adult: fluid given in the first 24h= Weight(kg) x TBSA % x 4ml Rate: ½ in the first 8h ¼ in the second 8 hrs ¼ in the third 8 hrs 38
- 39. Parkland’s formula For children: fluid given in the first 24h= Weight(kg) x TBSA % x 4ml Rate: ½ in the first 8h ¼ in the second 8 hrs ¼ in the third 8 hrs Add maintenance fluid as follows: 100ml /kg for first 10 kg of weight 50ml / kg for next 10kg of weight 20ml /kg for remaining 10kg after Keep urine out put 2ml /kg/h or more 39
- 40. Assess circulation hypotensive 20ml/kg bolus Repeat if still hypotension Parkland Formula: Crystalloid at 4mL/kg/d x TBSA Plus maintenance rate 1/2 over first 8 hours 1/2 over next 16 hours Normotensive Urine output < 1mL/kg/hr Urine output=1–3mL/kg/hr 20ml /kg bolus of Crystalloid Urine output > 3mL/kg/hr Decrease rate to 2/3 Parkland formula Continue Parkland formula 40
- 41. At the end of 24 hours, colloid infusion is begun at a rate of 0.5 ml x(total burn surface area (%))x(body weight (kg)), and maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml x(burn area)x(body weight). The end point to aim for is a urine output of 0.5- 1.0 ml/kg/hour in adults and 1.0-1.5 ml/kg/hour in children. 41
- 42. Criteria for burn admission Any partial-thickness burn >10% TBSA for child Any burn > 15 % of TBSA for adult Any full-thickness burn (5% TBSA) Any burns to airway compromise Circumferential burns limbs and chest Chemical ,radiation ,high voltage electrical burns Burns of critical areas, such as face, hands, feet, perineum, or joints Patient with underlying chronic illness, suspicion of abuse, or unsafe home environment, trauma Significant inhalational burn (excluding pure carbon monoxide poisoning) 42
- 43. Complications Infection Peripheral vascular resistance and hypovolemia Acute tubular necrosis Cardiac arrhythmias Cardiac arrest Electrolytes disturbance Shock 43
- 44. Extent of burn injury Minor burn injury Second-degree less than 15% TBSA in adults less than 10% TBSA in children Third-degree less than 2% TBSA not involving special care areas (eyes, ears, face, hands, feet, perineum, joints) Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (e.g, extremes of age, concurrent disease) 44
- 45. Moderate, Uncomplicated Burn Injury Second-degree burns of 15%–25% TBSA in adults and10%–20% in children Third-degree burns of less than 10% TBSA not involving special care areas Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (e g, extremes of age, concurrent disease) 45
- 46. Major Burn Injury Second-degree burns exceeding 25% TBSA in adults or 20% in children All third-degree burns exceeding 10% TBSA All burns involving eyes, ears, face, hands, feet, perineum, joints All inhalation injury, electrical injury, concurrent trauma, all poor-risk patients 46
- 47. First Aid For BURNS 47
- 48. Immediately cool the effect area with cool /runny water for at least 10 minute for all burns except electricity. Immerse the site in cold water to reduce pain and oedema and to minimize tissue damage. Water temp no less than 8 Celsius. . Do not use ice, because it may further damage the injured skin. If the area of the burn is large, after it has been doused with cool water, apply clean wraps about the burned area (or the whole patient) to prevent systemic heat loss and hypothermia. First Aid for BURNS 48
- 49. First Aid for BURNS Hypothermia is a particular risk in young children. Do not touch the wound with your hands or unsterile objects. Do not apply toothpaste, butter, grease or oil. They increase the risk of infection. Do not break blisters that may develop. If blisters break, clean the area by running tap water over it. Keep burned arms and legs above heart level. Do not stop cooling before 10 minute is up. 49
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- 51. Initial assessment of burn Initial assessment include : A: Airway with cervical spine stabilization B: Breathing C: Circulation D: Disability E: Exposure 51
- 52. Airway with cervical spine stabilization Secure the airway first Assess for signs of inhalation injury and oral scalds or because of severe burns to the face or oropharynx : (Hoarseness / stridor / dysphasia / drooling) History fire in an enclose space or fall. Consider intubation for >20%TBSA of burn e.g. House fire, Car fire, Toxic fumes (Industrial) 52
- 53. Breathing Assess for airway support. Assess rate and deep of breathing History of inhalation injury Listen: verify breath sounds Signs of cyanosis (late sign) If there are signs of breathing problems consider for intubation. 53
- 54. Circulation Sign of hypovolaemic shock If shock appear look elsewhere for a cause Color of skin Depth of burn (degree) Capillary refill Monitor Blood Pressure, Pulse, and Skin color. 54
- 55. Disability / Neurological LOC? AVPU Alert Respond to voice stimuli Respond to pain stimuli Unresponsive Pupil GCS 55
- 56. Exposure Stop burning process. Expose the patient (remove clothes and jewelry) Children with burn easy to lose heat so keep the child in warm environment and cover with clean dry blankets when no being examined. It is OK to use water to stop the burning process. 56
- 57. Nursing Care Plan Acute pain r/t destruction of skin /tissue AEB report of pain, numeric pain scale, HR↑,… Goal Expect outcome Intervention Evaluation -Decrease pain -Pt participate in activity, sleep, rest appropriate -Access pain scale -Give pain killer as order -Encourage express feeling about pain -Encourage use of stress management techniques progressive relaxation, deep breathing, guided imagery, and visualization . -Re-access pain -apprise to Dr. if pain not relieved ….. -Pain relieved -Vital sign in normal -Pt play -…. 57
- 58. Risk for fluid volume deficient r/t increase capillary permeability and evaporate from burn wound. Goal Expect outcome Intervention Evaluation - No sign of dehydration - Individual adequate urinary output with normal , stable vital signs, moist mucous membranes. -Assess sign of dehydration - Monitor vital sign - Monitor I & O - Estimate wound drainage and insensible losses. - Observe for gastric distension, hematemesis - …… -Pt no sign no dehydration -Normal I & O - …… 58
- 59. Risk for infection r/t skin intact / destruction of skin barrier / traumatic tissue. Goal Expect outcome Intervention Evaluation -wound healing free of purulent exudates and be afebrile. -No sign of infection -Assess sign of infection - Implement appropriate isolation techniques. - good hand washing technique for all individuals coming in contact with patient. -Use gowns, gloves, masks, and strict aseptic technique during direct wound care. -Monitor and/or limit visitors, if necessary. - Monitor vital signs for fever,….. -Wound heal with no sign of infection. -Pt no sign of fever. -……. 59
- 60. Treatment Relieving pain NONSTEROIDAL-ANTI- INFLAMMATORY DRUGS Preventing infection antibiotics Maintaining – body fluids electrolytes 60
- 61. References http://www.medicinenet.com/burns/article.htm APLS 5th Edition (advance peadiatric life support) The Harriet Lane Handbook19th_Edition_2 Josipa Bračić, Mentor: A. Žmegač Horvat: Burn Presentation Hospital care for children WHO First Aid For BURNS Presentation MANAGEMENT OF PATIENTS WITH BURN Presentation Burns First Aid and Treatment Options: Anas Bahnassi PhD 61
- 62. Thank you For your attendant Good luck For all ! 62
Editor's Notes
- #5: thick layer of fibrous and elastic tissue (made mostly of collagen, elastin, and fibrillin) that gives the skin its flexibility and strength. Collagen : សសៃទឹកប្រូតេអ៊ីន Flexible :អាចពត់បាន ទន់ រលាស៉ Insulate : ញែកចេញដោយឡែក
- #7: Friction : rubbing , trauma
- #10: A current of 1,000 volts or more is considered high voltage, but even the 110 volts of household current can be deadly.
- #11: Skin effects from ionizing radiation depend on the amount of exposure to the area, with hair loss seen after 3 Gy, redness seen after 10 Gy, wet skin peeling after 20 Gy, and necrosis after 30 Gy.
- #12: sulfuric acid as found in toilet cleaners, sodium hypochlorite as found in bleach, and halogenated hydrocarbons as found in paint remover Tissue destruction may continue for up to 72 hours after a chemical injury
- #13: Initial treatment includes rewarming in tepid (105°–110°F) water for 20–40 min
- #16: Singe: រោល Char : ក្រៀម ខ្លោច Pulmonary edema may not appear until 12 to 24 hours after the burn Decrease is surfactant production Decrease in ciliary action
- #20: Confined: កំណត់ព្រំដែន, បង្ខាំង, ទីកំណត់
- #21: Shiny: ភ្លិរលោង Tar :ជ័រ
- #36: Scatter : ពង្រាយ, ការខ្ចាត់ខ្ចាយ
- #41: At the end of 24 hours, colloid infusion is begun at a rate of 0.5 ml x(total burn surface area (%))x(body weight (kg)), and maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml x(burn area)x(body weight). The end point to aim for is a urine output of 0.5-1.0 ml/kg/hour in adults and 1.0-1.5 ml/kg/hour in children.
- #43: Burn in very young or older people.