1
Q
3 layers of skin
A
- epidermis (outermost)
- dermis
- SQ tissues/fat pads
2
Q
epidermis
A
- thin
- body vs. environment
3
Q
dermis
A
- hair follicles
- sweat/oil glands
- sensory nerves
- capillaries
4
Q
functions of your skin
A
- immunologic defense
- barrier
- thermoregulation
- neurosensory
5
Q
Causes of Burns
A
- inhalation
- thermal
- electrical
- chemical
- radiation
- cold thermal
6
Q
Prevalence of burns
A
birth to 2: scald, contact burns
5 to 20: thermal burns
20 percent pediatric burns r/t abuse or neglect
7
Q
inhalation
A
- results from hot air, noxious chemicals
- major predictor of mortality
- requires quick treatment
8
Q
inhalation injury types
A
- carbon monoxide poisoning
- inhalation injury above the glottis
- inhalation injury below the glottis
9
Q
Carbon monoxide Poisoning
A
- incomplete combustion of burning materials
- CO displaces O2
- skin has “cherry red” appearance
10
Q
Tx of CO Poisoning
A
- 100% humidified O2
- hyperbaric oxygen therapy
11
Q
CO displaces O2 causes…
A
- hypoxia
- carboxyhemoglobinemia
- death
12
Q
Inhalation injury above the glottis
A
- steam inhalation
- aspiration of scalding liquid
- hot smoke/air
- mucosal burns on oropharynx and larynx
- causes mechanical obstruction
- medical emergency
13
Q
Tx for injury above the glottis
A
- ABGs
- O2
- Intubation (Stridor)
14
Q
Inhalation clues
A
- facial/neck burns
- singed nasal hair, beard, eyelashes, eye brows
- hoarseness, painful swallowing
- darkened oral/nasal membranes
- hyper-secretions
- respirations distress
15
Q
Injury below the glottis
A
- usually chemical injury
- pulmonary edema may be instant or 12-24 hours later
16
Q
Tx for injury below the glottis
A
-intubation
17
Q
Pulmonary edema causes
A
- impaired cililary action
- hypersecreation
- edema
- ulceration of mucous membranes
- spasm of bronchi and bronchioles
18
Q
Thermal burns
A
- most common type of burn
- caused by flame, scald, sun/radiation, hot objects
19
Q
150 degree water…
A
1/2 second to get 3rd degree burn
20
Q
Hot water accounts for..
A
24 percent of all scalds in children
21
Q
US water burns..
A
65 percent of all children under 4 is from hot tap water
22
Q
1 million/year…
A
in US suffer from thermal burns
23
Q
45,000 are…
A
admitted to the hospital
24
Q
must eval for…
A
s/s of abuse
25
Initial tx for small burns
-cover with clean cloth, cool, tap water
26
initial tx for large burns
- ABCs
- do NOT immerse in cold water or ice pack
- wrap in clean, dry sheet or blanket
- remove burned clothing unless adhered to site
27
Electrical burns
- result of coagulation necrosis
- direct damage
- severity varies
- entry/exit points
- passes thru vital organs
- sparks
- inability to assess damage
28
electrical burns are high risk for...
- dysrhythmias
- metabolic acidosis
- myoglobinuria
29
Initial tx for electrical burns
- assure source is shut off
- remove the patient from source
- rescuer must be protected
30
Chemical burns
- destruction: acids, alkalis, organic compounds
- severity: agent, concentration, volume, duration of contact
- destroys tissue proteins and leads to necrosis
31
Chemical burns result in...
- skin
- eyes
- resp system
- liver and kidney damage
32
With chemical burns, alkali's..
- cause deeper penetration
- cause protein hydrolysis and liquefication
- damage continues
33
Destruction of tissue proteins leads to...
necrosis
34
Tx for chemical burns
- remove quickly from the skin
- remove saturated clothing
- brushing from skin in a powder
- irrigating with copious water
- burning process and tissue injury can last 72 hours
35
Cold Thermal
-varies from frostbite to systemic hypothermia
36
1ST degree frostbite
white/yellow firm plaque
-accompanying pain
37
2nd degree frostbite
- superficial blistering
- very painful
- clear or milky fluid
38
3rd degree frostbite
- deep blistering
| - red or purple fluid
39
Circumferential Burns
- chest or extremity
- completely surround the extremity or torso
- cause resp/circulatory compromise
- as fluid enters the circumferential burn pressure increases
40
Compartment Syndrome
- eschar is stiff and non-flexible
- high enough pressure impedes blood flow or resp effort
- creates ischemia
- can progress to necrosis
- requires "escharotomy"
- cut down to fat pads
41
Jackson's Burn Model
- middle: zone of coagulation
- next layer in to out: zone of stasis
- outermost layer: zone of hyperaemia
42
zone of coagulation
- severest damage
- will not recover
- slough out over time
43
zone of stasis
- less damaged tissue
- inflammation occurs
- vascularity damaged
- potential for full recovery
44
zone of hyperaemia
- intense vasodilation and increased blood flow
| - invades the other zones under appropriate conditions
45
1st degree burn
superficial
- epidermis only
- redness
- hypersensitivty
- painful to touch
- peeling skin
* sunburn
* short steam exposure
heals less than 7 days
46
2nd degree burn
superficial or deep partial thickness
- epidermis and part of the dermis
- red/weepy
- blistering
- edematous
- very painful
- blanch to touch
* scalds
* flash flame
* grease splatter
heals 2-3 weeks
can cause scarring
47
3rd degree burn
full thickness
- destruction of entire dermis
- white or charred
- all sensation lost
- eschar formation
- no blanch/blisters
* flame
* chemicals
* electrical
* explosions
-heals 4-8 wks for small
usually requires -sx/grafting
-always scarring
-highest risk of infection
48
Cardiovascular effects of a severe burn
- decreased BP (fluid movement from intravascular ro interstitial)
- Na+ and protein
- increased HR
- decreased CO
- decreased tissue perfusion
- F&E shifts
49
Insensible loss for severe burns
Norm: 30-50 ml/hr
| Severe burn: 200-400 ml/hr
50
Respiratory effects of a severe burn
- edema formation
- airway obstruction
- direct alveolar damage
- pneumonia, ARDS
51
GU effects of a severe burn
- decreased BF to kidneys
- renal ischemia
- acute tubular necrosis
52
GI effects of a severe burn
decreased peristalsis and ischemia
53
Phases of burn tx
- pre hospital
- emergent (resuscitative)
- acute (wound healing)
- rehab (restorative)
54
Pre-hospital initial management of burns
- drop and roll
- remove from source
- stop the burning
- primary survey A-F
- secondary survey, obtain info
55
Extent of burns: The rule of the 9's
???
56
Extent of burns: Lund-Browder chart
- more accurate
- recognizes percentage of BSA for various anatomic parts
- table for various ages
- head and trunk present larger proportions of BSA in children
57
Emergent Phase - Resuscitative
- time frame to resolve immediate problems resulting from the injury
- last 24-48 hours
- phase of fluid loss and edema formation
- lasts until fluid immobilization and diuresis starts
- F&E shifts: hypovolemic shock and hyperkalemia
58
Emergent Phase: Fluid resuscitation
- Ringer's Lactate used
- 2 large bore IVs
- half estimated volume given first 8 hours
- remainder of over next 16 hours
- rate increases or decreases by one-third if UO increases or decreases over 2-3 hours
59
Fluid formula for children
3-4 ml RL x kg x precentage BSA burns
60
Fluid formula for adult
2-4 ml RL x kg x percentage BSA burns
61
Management Principles
- universal precautions
- circulation management
- NG insertion
- Foley placement
- pain relief
- pulse assessment
- ventilatory evaluation
- emotional support
62
Acute Phase - Wound Healing
- begins with -mobilization of extracellular fluid
- hypernatremia
- hypokalemia
- necrotic tissue sloughs
- re-epithelialization begins
- partial thickness-heals from edges
- full thickness-requires skin grafts
63
Acute Phase: Wound cleansing and Wound debridement
- hydrotherapy
- 20-30 mins
- surgical cleansing agent
- eschar removal
- may be done in OR
*all care done aseptic
64
Burn Cream
- broad antimicrobial
- prevents wound sepsis
- applied 1-2x day
- applied immediately after hydrotherapy
- thin layers
65
Dressing Types
- Mepitel
| - Acticoat
66
Mepitel
low adherent, silicone gel
67
Acticoat: Partial Thickness
- partial thickness
- silver impregnated
- antimicrobial
- in place 3-7 days
- moistened with sterile water to activate
68
Acticoat: Full Thickness
- highly absorbent
- alginate
- last up to 3 days
- moist wound environment
- rayon/polyester core manages moisture level
- can be cut to desired shape and size
69
Surgical Skin Allografting
- done after debridement
- natural skin grafting
- thick or thin
70
Donor site of allografting
- dressed 1-2 wks
- heals 10-14 days
- lotion after
- looks flaked/dry
71
Graft site of allografting
- dressed 2-5 days
- protected from rubbing or pressure
- assures adherence
72
autograft
use of clients own skin
73
allograft
- use of skin from same species
| - human or cadaver
74
xenograft
use of porcine or bovine skin
75
Skin burn Disease Therapy
-Phase 1: utilizing a mixed skin cell prep, including the patient's skin stem cells, intra-op isolation and direct application
Phase 2: cell application with skin cell spray gun
Phase 3: cell and wound support with temp artifical would capillary system under the wound dressing
76
Artifical Skin
-dermagraft-TC
- made from human skin
- less surgical procedures
- less side effects
- decreased rejection
- $3600 sq ft
77
complications of artificial skin: infection
- partical thickness can become full thickness
- progress to transient bacteremia,
- sepsis
78
complications of artifical skin: cardiopulmonary
may carry over from emergent phase
79
complications of artifical skin: neurologic
- disorientation
- -ICU psychosis
- use of analgesics/anti-anxiety drugs
80
complications of artificial skin: musculoskeletal
- decreased ROM
| - contractures
81
complications of artificial skin: GI
- paralytic ileus
| - curling's ulcer
82
complications of artifical skin: endocrine
- elevated blood sugar
| - increased insulin production
83
Rehabilitative Phase (Restorative)
- emollient water-based cream, keeps skin moist and supple
- itching and flaking (benadryl)
- OT/PT
- psychological support
- knowledge deficit (dressing changes)
- potential reconstructive sx
84
Wound Care
"6 C's"
1. clothing
2. cooling
3. cleaning
4. chemoprophylaxis
5. covering
6. comforting
85
clothing
-clear skin of burned, chemically contaminated clothing
86
cooling
- apply gauze soaked in cool water
- 10 to 20 minutes
- relieves burning, pain, chemicals
- careful in small children or BSA greater than 10
-hypothermia risk
87
cleaning
- anesthetize (local, regional) first
| - mild soap and water and avoid disinfectants
88
chemoprophylaxis
- common pathogens, staph aureus,pseudomonas
- tetenus
- topical antibiotics (silvadene, bacitracin)
- biologic dressings
- non-biologic dressings: change daily
89
biologic dressings
- xenograft
- allograft (apply in 6 hrs) for endothelialization
-lower infection rate faster healing than antibiotics
90
covering
- first degree: no need for dressings, use topical skin lubricant
- second, third degree: clean wound, apply topical antibiotic, cover with sterile dressing
91
comforting
- NSAIDs: decrease inflammation, edema
| - Opioids : morphine
