Burns
Burns and Scalds kill >800
people per year in the U.K.
Those under 3 years and the elderly
most at risk e.g. dip burns, tip over scalds
Types of burns
Thermal, electrical, chemicals,
radiation, cold
Factors - temperature, exposure
time, conduction of heat into tissues
Scalds - hot water, steam,
Prevention
Fire guards Flame proof
clothes (especially children)
Supervision of children Care with hot
fluids
Avoid trailing flex - use coiled
flexes Cold water into bath
first
Smoke detectors
Assessment
Criteria for in-patient care
> 5% Full
thickness >10-15 cm2
Deep burns over joints/flexor surfaces Facial involvement
Suspicion of inhalation smoke/vapours Electrical or chemical burns
Social context, e.g. elderly living
alone, NAI Small burns can be
serious if not properly managed
History
Degree of inhalation
Effects may be delayed by several
hours
Electrical burns
Check ECG Check for an exit wound Deeper tissues may be involved
Chemical burns
Necrotising agents may be absorbed
into tissues Identify agent and
effects
Identify any specific antidotes
Airway burns
Suggested by; hoarseness, stridor,
dysphagia, facial and mouth burns, singeing of nasal hair, soot in mouth or
nose
Associated injuries
Bony and spinal injuries may occur as
a result of blasts or jumps to escape from a fire
Surface area involved - Rule of 9 for
adults
front torso = back torso = arm = leg =
head = groin = palm of hand =
Factors effecting mortality
Prior disease and pre-existing
condition Inhalation burn
increase mortality
% of body surface burnt
Local effects
In order of increasing severity
1.
Capillary dilation - redness -
fluid loss from capillaries - rise in interstitial pressure - stimulation of
pain receptors
2. Fluid
loss - blistering - death of epidermis involved
Regeneration
from adjacent epithelium
3. Destruction
of epidermis and upper part of dermis
Regeneration
takes place from epidermal elements in hair follicles and glands
healing
usually takes 10 - 14 days
4. Destruction
of the dermis only leaving epithelial elements in some deep glands and follicles in the adipose layer
Re-epithelialise
slowly leaving poor thin skin
5. Destruction
of all skin elements and underlying tissue
Will
not heal without surgical intervention
Classification
From sensation tests and history
Describe the % involvement for the
different classifications
Superficial (1st degree)
Relatively minor erythema Loss of part of epidermis only
May be extremely painful due to
damaged or exposed nociceptors
Healing is spontaneous
Partial thickness (2nd
degree)
Loss of part of the dermis Deeper skin structures remain
Healing may be slowish May heal with or without a
scar
Full thickness (3rd degree)
Loss of full dermal thickness Possible loss of deeper structures
Not painful Do not blister
Heal only by grafting
Systemic effects
Shock
Fluid loss ----- hypovolaemia -----
shock ----- complications of shock
Hypovolaemia ----- constriction of
peripheral vessels
Pulse -
compensatory tachycardia, fast weak thready
BP -
starts to fall as tachycardia fails to compensate
Poor tissue perfusion ----- renal hypoperfusion ------- failure
Acidosis, changes in acid base balance
Protein loss in exudate ------- osmotic changes in plasma
Thirst
Hypoxia
COHb ABGs Constriction from chest burns Airway swelling
Give high concentrations of oxygen
Infection
Further local tissue loss and pain Spread of infection to healthy
tissues
Bacteraemia --- septicaemia --- shock Scarring
Pain
May require iv. opiates and
antiemetics
Gastrointestinal changes
Increased sympathetic activity ------
reduced peristalsis ------ possible ileus
Gastric mucosal ischaemic ------
peptic ulceration ------ occult blood
haemorrhage and haematemesis
Metabolic changes
Cellular breakdown ----- increased K+
Inhalation problems
Carbon Monoxide poisoning -
Carboxyhaemoglobin
Small volumes of soot particles are
filtered larger amounts may enter lungs
Superheating may burn nasal mucosa and
lower tissues in the respiratory tract
Pulmonary oedema
Upper airway obstruction may occur up
to 48 hours after the burn, due to pharyngeal and laryngeal oedema.
Neck oedema may cause tracheal
compression.
Tourniquet effect on breathing from
chest burns.
Burning Plastic - toxic fumes eg. Hydrogen cyanide, Hydrochloric acid,
Sulphuric acid
First aid
A
B C
Remove the heat from the hot tissue to
prevent ongoing necrosis
Cold water
Removes heat so limits tissue damage Eases pain
Removes caustic agents Usually
20 minutes in more extensive burns
Flame burn
Put out flame Remove
from smoke
Do not remove adherent burnt clothes Dousing with cold water
Chemical burn
Eyes -
irrigate with water
Cement and lime - use large volumes of water
Use specific antidotes if known,
indicated and available
Scalds
Remove clothing wet with hot water or
steam
Apply cold water for 10 - 15 minutes
to prevent tissue necrosis and limit pain
Electrical burns
Remove patient from current, without
electrocuting yourself.
Check for cardiac and respiratory
function - CPR if indicated
Ensure power is off before application
of water
Wrap in towel or sheet which has been
soaked in cold water.
Irrigate for a long time
First aid dressings
Water Wet
compresses for transportation
Wet towels (Sterile if possible) Non-adherent dressings
Do not use antiseptics or antibiotics Do not apply, butter, honey, flour,
etc.
Cling film or polythene bags as a
temporary first aid dressings after use of water, may also be used to may be
used to retain a compress
Systemic management
Fluid replacement
Oral replacements; in adults for < 10% in children for < 15%
If greater areas involved IVT is
essential
Mount Vernon Formula % body area burnt x
weight (Kg)
2
This indicates the amount of iv
colloid in mls required during each of the six "shock periods" of the
first 36 hours
Shock periods in hours - 4, 4,
4, 6, 6, 12
Start from time of injury
Crystalloids are also required for
fluid and sodium replacement
Formulas are only a starting point
Further titration based on Urine
output, blood tests, patient response and CVP
Full fluid balance recording -
catheterise
Other systemic management
Analgesia Tetanus
toxoide
Possible systemic antibiotics Wound dressing
NBM until ileus has been assessed H2 blockers
Ongoing management/rehabilitation
Monitor weight
Diet - burns induce a hypercatabolic
state - when able ample protein and carbohydrate with possible supplementation
Aid with alteration in body image
Involve family
Physiotherapy
Prevent contractures Complications of immobility
Minimise muscle wasting Occupational therapy
Local management options
Surgery
Contracture release Scar
revision
Exposed (open)
For areas difficult to dress eg. face Nurse in a single room
Semi-open
Covered with a topical agent and gauze
Closed
Paraffin gauze or Flamazine very well
covered with dressing
Changed 24 or 48 hourly
Superficial
Hydrocolloids, films, chlorhexidine,
aqueous povidine iodine
Full thickness
Silver sulphadiazine
Hands
Plastic or PTFE bags to allow movement
and physiotherapy
Prevent infection
Isolation Strict asepsis Debridement
as required
Culture and sensitivity Topical antibiotics Topical antiseptics
Skin grafting
Other complications
Bronchopneumonia - smoke or heat
damage to lungs
Renal failure DVT and other complications of immobility
Stress diabetes Psychological stress effects
Management principles
Prevent shock and hypoxia Limit tissue damage
Prevent infection - burns are easily
infected Stretch areas over
joints, or leave mobile
Promote healing Loss of
normal functions of the skin
Questions
1.
A burn involving all of the left arm in an adult female would represent
damage to approximately what percentage of the skin surface?
a.
4.5% b. 9% c. 18% d. 22%
2. The palm of the hand approximates
to what percentage of the skin surface?
a.
1% b. 2% c. 3% d. 4%
3.
The usual mortality rate in the U.K. from burns is in the order of,
a.
100 deaths per year b. 400
deaths per year
c.
800 deaths per year d. 1000 deaths per year
4.
A partial thickness burn is one in which,
a.
Only part of the epidermis is burnt b. All of the epidermis and part of the dermis
is burnt
c. All of the dermis is burnt d.
Part of the subcutaneous tissue is burnt
5.
Which of the following statements are true?
a.
A full thickness burn will be more painful than a partial thickness burn
b.
A partial thickness burn will be more painful than a superficial burn
c.
A superficial burn may be more painful than a full thickness burn
d. Many burns are so painful they require
opiates in hospital to control the pain
6.
A child tips a hot cup of tea over his arm. Which of the following actions would you
carry out immediately?
a.
Wrap the arm in damp towels
b.
Apply a thick layer of butter or other fatty material to
the arm
c.
Immerse the arm in cold water d. Immerse the arm in tepid
water
7.
A mechanic splashes some battery acid in his eye. Which of the following should be carried out
first?
a.
Neutralise the acid with an irrigation of water and baking soda
b.
Place a firm pad over the eye and take the mechanic to hospital
c.
Encourage tear production by stimulation of the cornea
d.
Irrigate the eye under running water
Why would you want to know the
following?
If the patient had been burnt in an
explosion
If the fire and patient had been in an
enclosed space
The nature of the burning material
Why would the following assessments be
carried out?
Pulse
BP
Surface area burns
Assessment of burn depth
What are the possible causes of shock
after burns
What factors may contribute to hypoxia
after a burn
What factors may contribute to the
development of renal failure
How would you treat blisters
What classification of burn causes
blisters