Burn Trauma Injuries-5 Nursing CEs

Author: Brooke Baldwin-Rodriguez RN MSN WCC

Written: June 26^th, 2007

Updated: September 25, 2009

Course Description

This course is designed to review the overall management of the burn injured patient. Foundational knowledge of burn care will begin with a review of the anatomy and physiology of skin. Mechanisms of burn injury and pathophysiological concepts related to burn injuries. Focus will be on general systemic manifestations of burn injuries, treatment of burn injuries and wound management. Special concerns regarding the burn injured patient will be highlighted and emphasized. The role of the nurse in providing care will be discussed and common nursing diagnoses presented. The phases of burn care will be the final focus of the course.

Course Objectives

·        Review the incidence, prevalence, and mortality of burn injuries

·        Review the anatomy and physiology of the integumentary system

·        Describe the mechanisms of injury for burns

·        Relate clinical presentation of inhalation injuries to the mechanism of injury

·        Prioritize interventions for a client with an inhalation injury

·        Compare and contrast type of burn injuries

·        Describe the classification of burn injuries

·        List guidelines for referral to a burn center

·        Discuss the pathophysiology of burns

·        Describe fluid shifts that result from burn injury

·        Name special consideration and areas of special consideration for burns

·        Relate how age, medical history, and concomitant injury impact the burn victims’ recovery

·        Describe phases of burn care and general management and interventions

·        Discuss collaborative management of burns

·        Prioritize nursing care for the resuscitative, acute, and rehabilitative phase of burn injury

·        Identify Nursing diagnoses, interventions, and expected outcomes for burn victims

·        Describe rehabilitative care for the client with a burn injury

Incidence/Prevalence/Mortality:

·        Burn trauma is the third leading cause of injury and or death in the United States (the U.S. also has the highest burn injury rate of all industrial countries). 

·        There are approximately 2 million burn victims in the United States each year that require medical care. Approximately 70, 000 of burn injuries require inpatient medical care and there are about 12,000 deaths a year. Males are more commonly burned and have a higher mortality than females.

• Burn injuries are defined as tissue injury due to the coagulation of cellular proteins as a result of heat produced by thermal, chemical, electrical, or radiation energy.
• A major burn is defined as any burn that compromises greater the 25% of the victim’s total body surface requiring rapid assessment and treatment.
• The most common types of burns are thermal (a burn from a heat source), chemical, electrical, steam or radiation.
• The skin (which is the largest organ of the body) is the first defense against injury, infection, body temperature control, fluid loss and sensory interaction. Injury to this crucial organ can have a negative impact on the entire human system.

Anatomy & Physiology of the Skin:

Skin is the largest organ of the body and provides many crucial functions:

·        Protection against infection and injury

·        Regulation of fluid loss

·        Temperature control

·        Synthesis of vitamin D

·        Sensation

·        Physical: identity and cosmetic appearance

The Layers and Function of the Skin:

The skin has three major tissue layers and is considered to be the largest organ in the human body. The following describes each of these layers:

Epidermis – this is the outer most layer of the skin and is composed of stratified epithelium. The epidermis has two major components with the outer layer consisting of anucleated cornified cells (known as the stratum corneum). The stratum corneum covers the inner layer of the epidermis which is known as the Malpighian layer (this is where the cornified surface cells arise and differentiate). The stratum corneum acts as a barrier and protects the body from microorganisms and toxic substances. It also allows the body to retain water and electrolytes. The Malpighian layers (inner layers) provide a continuous production of corneum cells.

Dermis – the dermis is located beneath the epidermis and is composed of dense fibroelastic connective tissue that contains collagen and elastic fibers and an extracellular gel (of sorts). This gel is comprised of an acid mucopolysaccharide protein, salt, water and glycoproteins that work together to support the dermis as well as participate in collagen synthesis. The dermal layer also contains an extensive nerve and vascular network, special glands and appendages, blood, lymph vessels, sweat glands, hair follicles and sebaceous glands which communicate with the dermis. The dermis can further be divided into two parts which are known as the papillary dermis (the more superficial portion) and the reticular dermis (the more dense and thick portion).

Subcutaneous – this third layer of the skin is composed primarily of areolar and fatty connective tissue. The subcutaneous tissue varies in thickness and adipose content and contains skin appendages, glands and hair follicles. Each hair follicle consists of a shaft that extends above the surface of the skin, and a root that is embedded within the skin.

Sweat Glands – there are two types of sweat glands which are known as the aprocrine and eccrine. The aprocrine glands have one duct that opens into a hair follicle and are largely confined to the axillary and perineal region of the body (they do not become functional until puberty). The eccrine glands are simple, coiled, tubular glands that extend into the papillary dermis. These glands open onto the skin surface and are independent of hair follicles.

Sebaceous Glands – these glands are simple or branched alveolar glands that are for the most part connected to hair follicles.

Mechanism of Injury:

Thermal burns – Thermal burns constitute almost 90% of burn injuries. Skin that comes in contact with a source of increased temperature results in a thermal burn. Flame, scalding liquids, steam, and hot object are common sources of thermal burns. Severity of the burn is related to heat intensity and duration of contact (the higher the temperature and longer the contact with the heat source = deeper, more severe burn.) Thermal burns occur at temperatures above 40 degree Celsius (111.2 degrees Fahrenheit). Full thickness tissue destruction can happen in as little as 3 to 5 seconds with temperatures of 60 degrees Celsius (140 degrees Fahrenheit). Extremities of age, children and the elderly, are at greater risk of burn wound injury due to thinner skin and.

Chemical burns – Chemical burns are the cause of less than 10% of all burn injuries. Injury can be caused by contact, inhalation of fumes, ingestion, or injection of chemicals. The result of a chemical burn can have both local and systemic effects on the body. Severity is related to type, volume, duration of contact, quantity of the chemical, extent of tissue penetration, and concentration of the agent. Tissue damage continues until chemical is removed or neutralized. Categories of chemical burns include:

• Strong acids: sulfuric and muriatic acid

• Alkalis: lime (cement), ammonia, caustics
• Vesicants: Dimethyl sulfoxide, chemical warfare agents
• Corrosives: phenol, lye, white phosphorus

One of the main concerns for healthcare providers when caring for chemical burns is to provide protection for self first prior to treating the injured burn patient. Dry chemical are brushed-off and liquid chemicals are flushed with copious amounts of water. All clothing should be removed and thrown away.

Electrical burns – Electrical burns are associated with less than 10% of burn injuries. Contact with household current, car batteries, electrosurgical devices, high-tension electrical wires, and lightening are common causes of electrical injury. Electrical injuries are classified as either a high-voltage, greater than 1,000 volts of energy, or low-voltage, less than 1,000 volts of energy. Injury from electrical burns is a result of the type of electrical current pathway, duration of contact, environmental conditions, and resistance of body tissues. Electricity follows through the path of least resistance. Generally, nerves, blood vessels, and muscles have the highest risk of damage. Nerve tissues have the least resistance and bone tissue has greater resistance. It is expected that electrical burn injuries will have both entrance and exit wounds. Presence of both entrance and exit wounds should be assessed on every burn suspected of being caused by electricity. It is not always possible to assess total burn surface area due to the unknown amount of internal injury. Total body surface area of a burn may not be known calculation of resuscitation volume may be difficult. Often, electrical burns require larger volumes of fluid resuscitation due to myoglobinuria due to muscle damage and breakdown. Urine output should be maintained at 75 –100ml/hour when myoglobin is detected in the urine. There is a high risk of hypoxia due to paralysis of respiratory muscles and continuous cardiac monitoring is essential for the detection of dysrhythmias or ectopy. A high risk of cardiopulmonary arrest is associated with electrical burns. Goals of treatment are aimed at maintaining peripheral circulation. Assessment of skin color, sensation, capillary refill, and peripheral pulses is essential. Remove rings, watches, and other jewelry due to the swelling that often accompanies fluid resuscitation. Muscle compartment syndrome is a known complication of electrical burn injuries and any detected decrease in blood flow to extremities or central body area (i.e. the chest) should elicit prompt assessment for whether an escharotomy or fasciotomy needs to be initiated.

Radiation Burns – Radiation burns include nuclear sources (some ultraviolet light has radiation). In addition to determining the method of a burn, determining the degree of the burn is also an important assessment in order to develop an appropriate plan of care. Determining the extent of a burn is also important in order to evaluate the potential for infection, the tissue exposure and invasion of the circulatory system.

Inhalation injury – Inhalation injury is observed in 20% to 50% of patients admitted to burn centers. Lung injury is secondary to the inhalation of smoke and products of incomplete combustion. Incomplete combustion of smoke products can produce carbon monoxide. Carbon monoxide poisoning occurs because carbon monoxide has an affinity for hemoglobin 200 times greater than that of oxygen. When carbon monoxide is combined with hemoglobin oxygen cannot be transported via red blood cells and the body tissues do not receive the requisite oxygen for cell metabolism; the result is hypoxia. Inhalation injury includes injury above the glottis and injury below the glottis. Injury above the glottis is referred to upper airway injury. Upper airway injury causes edema and has a high risk of airway obstruction. A patient may present with hoarseness, dry cough, labored or rapid breathing, difficulty swallowing, or stridor. Injury below the glottis can cause extensive damage to alveoli. Carbonaceous sputum is a hallmark sign injury below the glottis. Bronchial constriction and spasms can occur within several minutes to hours after injury and can lead to acute respiratory failure and acute respiratory distress syndrome within the first few days. Respiratory tract mucosal sloughing may occur within 4 to 5 days. Bronchoscopy can be used to definitively diagnose injury below the glottis.

Burn Classification & Severity:

Burn classification and severity are determined by type of burn injury, burn wound characteristics, concomitant injuries, patient age, and preexisting health status. The American Burn Association guidelines for referral to a burn center are as follows:

• Partial-thickness burns >10% total body surface area
• Full thickness burns in any age group
• Burns involving the face, hands, feet, genitalia, perineum, or major joints
• Chemical burns
• Electrical burns
• Presence of inhalation injury
• Preexisting medical conditions that could complicate management, prolong recovery, or affect mortality
• Associated trauma
• Hospitals without qualified personnel or equipment to care for burn-injured children
• Burn injuries in patients who will require special social, emotional, or long term rehabilitative intervention

Severity of burn injuries are classified as minor, moderate or major. Minor burns are those that are partial-thickness burns less than 15% total body surface area (TBSA) in adults and less than 10% total body surface area in children and do not apply to burns that include includes eyes, ears, face, hands, feet, or perineum. Minor burns also include full-thickness burns less than 2% TBSA in adults and children. Moderate burns are those partial-thickness burns between 15% and 25% in adults and between 10% and 20% TBSA in children or less than 10% full-thickness burn. This category also excludes burns to the eyes, ears, face, hands, feet, or perineum, which always need specialized burn care. Major burn injuries are partial-thickness burns above 25% in adults or above 20% in children. Full-thickness burns greater than 10% TBSA are also included.

Depth of burn injury predicts wound care treatment, determines need for skin grafting, scarring, cosmetic, and functional outcomes.

Classification by depth:

• Superficial burns affect the first layer of skin only, the epidermis, and typically heal in 3 to 5 days without treatment. No calculation of burn size is needed.
• Partial-thickness burns involve the dermal layer of skin and are divided into superficial partial-thickness burns, deep partial-thickness burns, and full-thickness burns.
  • Superficial partial-thickness affects the epidermis and a limited portion of the dermis and is pink to red in color. Slight edema may be visible with pain upon touch. Healing should occur in 3 to 5 days.
  • Deep partial-thickness affects epidermis and most of the dermis. These burns may heal spontaneously within 3 to 6 weeks and skin grafting may necessary.
  • Full-thickness burns lead to destruction of all layers of the skin down to or past the subcutaneous layer, fascia, muscles, or bone. Full-thickness burns have thick, leathery, non-elastic, coagulated layer of eschar. Nerves are destroyed, so the burn at this depth may be painless. Skin grafting is always required for permanent closure with longer than 1 month healing time. Accurate depth assessment may be difficult to determine initially during the first 48 to 72 hours.

Zones of thermal injury explain the relationship of depth and extent of injury.

·        Zone of hyperemia: Outermost area of minimal injury, similar to a superficial burn and heals rapidly, there is no cell death. Tissue is red but blanches.

·        Zone of coagulation: Greatest area of tissue necrosis and is at the core of the wound. The tissue in this area reached at least 45 degrees Celsius (113 degrees Fahrenheit). Protein coagulation and cell death has occurred. Tissue is expected to be black, gray, or khaki to white and does not blanch with pressure.

·        Zone of stasis: Area directly next to the zone of coagulation with vascular damage (reduced blood flow) and potentially reversible injury. Tissue is red but does not blanch with pressure. Adequate resuscitation to correct hypovolemia and restore blood flow is essential for recovery.

The extent of injury is expressed as percentage of total body surface area (%TBSA). The rule of nines is used to quickly calculate the %TBSA and is also used to calculate the surface area of irregular of scattered small burns. The palm of the patient’s palm (including fingers) is used to represent 1%. This method varies in adults and pediatrics due to differences in head surface area proportion in children.

The “rule of nines” based on the body divided into areas representing 9%:

• Head – 9%
• Right Arm – 9%
• Left Arm – 9%
• Chest – 9%
• Abdomen – 9%
• Upper Back – 9%
• Lower Back – 9%
• Right Thigh – 9%
• Left Thigh – 9%
• Right Leg (below the knee) 9%
• Left Leg (below the knee) 9%
• The last 1% covers the genital area

The Lund and Browder Chart provides more accurate determination of the extent of burn injury and correlates more accurately with body surface area with age-related proportions. The Lund and Browder method is the most frequently used method at burn centers and is used to calculate fluid resuscitation.

Physiologic Response to Burn Injury:

Burns greater than 20% or 30% TBSA have both local and systemic effects.

The local response to burn injury leads to coagulation of cellular proteins, production of complement, production of histamine, and production of oxygen free radicals. Activation of the complement system and histamine leads to increased vascular permeability. Oxygen free radicals create tissue injury and the formation of edema. Consequences of edema include pulmonary vascular injury, pulmonary interstitial edema, intra-alveolar hemorrhage, red blood cell destruction and intravascular hemolysis. Total cell destruction may occur due to alterations in the structure of DNA.

Systemic manifestations and response to burn injury begins with systemic inflammatory response syndrome (SIRS) and the release of mediators. Vasoactive substances are released along with the stress hormones cortisol, glucagon, and epinephrine.

The local and systemic responses produce the hallmark factors that are identified with burn injuries.

·        Fluid shifts from blood to interstitial and intracellular spaces that lead to marked edema formation due to the decreased capillary oncotic pressure and increased interstitial oncotic pressure

·        Tissue edema that may lead to airway instability, respiratory failure, limb ischemia, and compartment syndromes

·        Hemoconcentration due to increase blood viscosity

·        Decreased intravascular volume that leads to severe hypovolemia that lead to the need for significant fluid resuscitation

·        Burn hypermetabolism which causes increased oxygen consumption, negative nitrogen and potassium balance, excessive muscle wasting, glucose intolerance, hyperinsulinemia, insulin resistance, sodium retention, and peripheral leukocytosis

Burn injuries affect the systems of the body in the following ways:

Cardiovascular Response

·        Third space fluid shifts

·        Decreased cardiac output

·        Increased systemic vascular resistance (SVR) due to catecholamine-induced vasoconstriction

·        Hypotension

·        Tachycardia

·        Decreased pulses

·        Prolonged capillary refill

·        Myocardial depression due to the release of tumor necrosis factor (TNF) and interleukins

Defense Mechanisms

• Over stimulation of suppressor T cells
• Complement activation
• Decreased T helper cells, T killer cells + polymorphonuclear leukocyte activity
• Increased risk of opportunistic infections until burn wound closes

Pulmonary

• Release of vasocontrictive agents
• Decreased ability to oxygenate
• Airway edema
• Singed nasal hairs
• Soot tinged sputum
• Change in voice
• Coughing
• Drooling
• Rapid or labored breathing
• Crackles
• Stridor

Renal

• Hypovolemia and redistribution of blood flow to vital organs leads to decreased glomerular filtration rate
• Oliguria
• Increased specific gravity
• Acute tubular necrosis

Gastrointestinal

• Response due to hypovolemia
• Inflammatory response may lead to impaired gastric mobility and paralytic ileus
• Stress ulcers my result from stress response, leading to Curling’s ulcer

Metabolic response

• Increase secretion of catecholamines, cortisol, and glucagons to support tissue repair
• Hypermetabolism
• Protein wasting
• Weight loss
• Degree of response based on %TBSA, age, sex, nutritional status, preexisting medical conditions

Fluids & Electrolytes

• Fluid shift
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