Strongest predictors for mortality in burn injuries (3)
- Increased percent of TBSA burned
- Presence of inhalation injury
- Increased age
Burns Gerontologic Considerations (2)
Increased mortality
Delayed wound healing
Zone of Coagulation
Innermost, no recovery possible, necrosis, greatest injury
Zone of Stasis
- Has reduced blood flow to vascular damage
- Injured cells may remain viable
- If persistent ischemia → necrosis will occur in 24 - 48 hours
Zone of Hyperemia
- Minimal injury, superficial burn
* May fully recover spontaneously
Superficial
1st degree
Epidermis intact with erythema
If rubbed, burned tissue does not separate from underlying dermis
Sunburn or superficial scald
Partial thickness
2nd degree
• Epidermis & some dermis damage
• Painful and associated with blister formation
• Healing time based on depth of dermal injury : 2-3 wks • Hair follicles & skin appendages intact
Full thickness
3rd degree
• Total destruction of epidermis, dermis & underlying tissue
• Wound color : pale white, red, brown, or charred
• Burned area lacks sensation (damaged nerves)
• Skin leathery & dry: destruction of microcirculation, hair follicles & sweat glands
• Severity of burn deceiving: no pain
Deep necrosis
4th degree
Injuries extend into deep tissue, muscle or bone
Rule of Nines
- Most common method used to estimate extent of burns in adults
- Based on anatomic regions, each representing approximately 9% of TBSA
- Allows clinicians to quickly obtain estimate of burn size
Lund & Browder Method
- More precise reliable estimate of TBSA burned
- More detailed consideration to % surface area of various body parts
- Relates to age of patient
Palmer method
- Good for patients with scattered burns
* Patient’s hand, including fingers, is approximately 1% of patient’s TBSA
Physiological response to burns
- Acute inflammation and intravascular coagulation
* Altered vascular permeability: third spacing
Early Priority of Care for burns
- Airway, breathing
- Fluid and electrolyte balance: massive fluid and lyte loss
- Acid-base balance: massive fluid and lyte loss, tissue degradation
Cardiovascular Alterations
hypovolemia edema--> airway decreased CO increased O2 demand decreased BP
Fluid & Electrolyte Alterations
- Deeper: edema up to 18 h post-injury
- ↑K from massive cell destruction; ↓ K later with fluid shifts
- ↓ Na+ : resulting from plasma resuscitation
Pulmonary Alterations
Bronchoconstriction
• Release of histamine, serotonin, & thromboxane &
chest constriction
Catecholamine release alters peripheral blood flow, reduction O2 delivery to tissues
Edema can cause obstruction up to 48 h after burn
Renal alterations
↓ blood volume
↓ UO : ↓ GFR
Thermoregulatory alterations
inability to regulate temp
GI alterations
- Paralytic ileus
- Curling’s ulcer
- Translocation of bacteria
3 phases of care
- Emergent/ Resuscitative
- Acute/Intermediate
- Rehabilitation
Resuscitative phase
Remove patient from source & stop burning process
• Immediate primary survey of patient to assess the ABCDEs:
Rescue workers’ priorities
• Establish an airway, administer O2 (100% if carbon monoxide poisoning is suspected)
• Inserting large-bore IV line
• Cover wound with clean, dry cloth or gauze
• Immediate continuous irrigation of chemical injury
ABCDE
Airway Breathing Circulation Disability Exposure
Fluid Resuscitation
- Under-resuscitation: Shock, MODS
- Over-resuscitation: HF, pulmonary edema
- LR is crystalloid of choice
