Tuesday, May 2, 2017

Introduction to Burns

A major burn is a horrifying injury, necessitating painful treatment and a long period of rehabilitation. It’s often fatal or permanently disfiguring and incapacitating (emotionally and physically). In the United States, about 2.5 million people annually suffer burns. It’s the nation’s third leading cause of accidental death.

Thermal burns, the most common type, are caused by flame, flash, scald or contact with hot objects. Examples are residential fires, motor vehicle accidents, playing with matches, improperly stored gasoline, space heater or electrical malfunctions, or arson. Other causes include improper handling of firecrackers, scalding accidents, and kitchen accidents (such as a child climbing on top of a stove or grabbing a hot iron). Burns in children are sometimes traced to parental abuse.
Chemical burns result from the contact, ingestion, inhalation, or injection of acids, alkalis, or vesicants that cause tissue injury and necrosis. 
Electrical burns result from coagulation necrosis caused by intense heat; they usually occur after contact with faulty electrical wiring or high-voltage power lines or when electric cords are chewed (by young children). Friction or abrasion burns happen when the skin is rubbed harshly against a coarse surface. 
Sunburn, of course, follows excessive exposure to sunlight.
Signs and symptoms
Symptoms will vary depending on the degree of burn. Suspect burn injury when the patient presents with blisters, pain, peeling skin, red skin, edema, white or charred skin, or signs of shock. Suspect an airway burn if you see charred mouth, burned lips, burns on the head, neck, or face; wheezing, change in voice, difficulty breathing and coughing; singed nose hairs or eyebrows; or dark carbon-stained mucous.
The depth of damage to the skin and tissue and the size of the burn are important factors in burn assessment.

Depth of skin and tissue damage
A traditional method gauges burn depth by degrees, although most burns are a combination of different degrees and thicknesses.
First-degree—Damage is limited to the epidermis, causing erythema and pain.
Second-degree—The epidermis and part of the dermis are damaged, producing blisters and mild-to-moderate edema and pain.
Third-degree—The epidermis and the dermis are damaged. No blisters appear, but white, brown, or black leathery tissue and thrombosed vessels are visible.
Fourth-degree—Damage extends through deeply charred subcutaneous tissue to muscle and bone.
Burn size
The size is usually expressed as the percentage of body surface area (BSA) covered by the burn. The Rule of Nines chart most commonly provides this estimate, although the Lund-Browder classification is more accurate because it allows for BSA changes with age. A correlation of the burn’s depth and size permits an estimate of its severity.
Major—third-degree burns on more than 10% of BSA; second-degree burns on more than 25% of adult BSA (more than 20% in children); burns of hands, face, feet, or genitalia; burns complicated by fractures or respiratory damage; electrical burns; all burns in poor-risk patients
Moderate—third-degree burns on 2% to 10% of BSA; second-degree burns on 15% to 25% of adult BSA (10% to 20% in children)
Minor—third-degree burns on less than 2% of BSA; second-degree burns on less than 15% of adult BSA (10% in children).
Other considerations
Location: Burns on the face, hands, feet, and genitalia are the most serious because of possible loss of function.
Configuration: Circumferential burns can cause total occlusion of circulation in an extremity as a result of edema. Burns on the neck can produce airway obstruction, whereas burns on the chest can lead to restricted respiratory expansion
History of complicating medical problems: Note disorders that impair peripheral circulation, especially diabetes, peripheral vascular disease, and chronic alcohol abuse.
Other injuries: Consider injuries sustained at the time of the burn such as with a blast injury or motor vehicle accident.
Pulmonary injury: Smoke inhalation can cause pulmonary injury
1. Immediate, aggressive burn treatment increases the patient’s chance for survival. Later, supportive measures and strict aseptic technique can minimize infection. Meticulous, comprehensive burn care can make the difference between life and death.
2. If the patient’s burns are minor, immerse the burned area in cool water (55° F [12.8° C]) or apply cool compresses. Give him pain medication as needed.

3. Debride the devitalized tissue, taking care not to break any blisters. Cover the wound with an antimicrobial and a bulky, nonstick dressing, and administer tetanus prophylaxis as needed.

4. Provide the patient with thorough teaching and complete aftercare instructions. Stress the importance of keeping the dressing dry and clean, elevating the burned extremity for the first 24 hours, taking the prescribed analgesic, and returning for a wound check in 1 to 2 days.
5. For moderate and major burns, immediately assess the patient’s airway, breathing, and circulation. Be especially alert for signs of smoke inhalation and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum. Assist with endotracheal intubation, and administer 100% oxygen.
Control bleeding, and remove smoldering clothing, rings, and other constricting items.

6. Be sure to cover burns with a clean, dry, sterile bed sheet. (Never cover large burns with saline-soaked dressings because they can drastically lower body temperature.)
7. Begin I.V. therapy immediately to prevent hypovolemic shock and maintain cardiac output. Use lactated Ringer’s solution or a fluid replacement formula
8. Once the patient’s condition is stable, take a brief history of the burn.
9. Draw blood samples for a complete blood count; electrolyte, glucose, blood urea nitrogen, and creatinine levels; arterial blood gas analysis; and typing and cross matching.
10. Closely monitor intake and output, and frequently check vital signs. Although it may make you nervous, don’t be afraid to take the patient’s blood pressure because of burned limbs. An arterial line may be inserted if blood pressure is unobtainable with a cuff.
In the facility, a central venous pressure line, additional I.V. lines (using venous cutdown, if necessary), and an indwelling urinary catheter may be inserted.
To combat fluid evaporation through the burn and the release of fluid into interstitial spaces (possibly resulting in hypovolemic shock), continue fluid therapy as needed.
11. Send a urine specimen to the laboratory to check for myoglobinuria and hemoglobinuria.
12. Insert a nasogastric tube to decompress the stomach and avoid aspiration of stomach contents.
13. Electrical and chemical burns demand special attention. Tissue damage from electrical burns is difficult to assess because internal destruction along the conduction pathway is usually greater than the surface burn would indicate. Electrical burns that ignite the patient’s clothes may cause thermal burns as well. If the electric shock caused ventricular fibrillation and cardiac and respiratory arrest, begin cardiopulmonary resuscitation at once. Get an estimate of the voltage.
For a chemical burn, irrigate the wound with copious amounts of water or normal saline solution.

14. If the chemical entered the patient’s eyes, flush them with large amounts of water or saline solution for at least 30 minutes; for an alkali burn, irrigate until the pH of the cul-de-sacs returns to normal.
Have the patient close his eyes, and cover them with a dry, sterile dressing. Note the type of chemical causing the burn and the presence of any noxious fumes. The patient will need an emergency ophthalmologic examination.
15. If the patient is to be transferred to a specialized burn care unit within 4 hours after the burn, don’t treat the burn wound itself in the emergency department. Instead, prepare the patient for transport by wrapping him in a sterile sheet and a blanket for warmth and elevating the burned extremity to decrease edema. Then, transport the patient immediately. Once at the burn unit, the patient will receive specialized treatments, including skin grafts of various types.

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