ALM # 3 BURNS
Case Presentation:
21 y/o male involved in industrial fire. Patient was welding a steel structure when a
spark from the torch ignited a barrel of flammable material that was inadvertently placed
in his work area. Patient sustained full-thickness burns over the upper half of his chest
and circumferential burns to bilateral arms. Patient also sustained superficial partialthickness burns to face, neck and bilateral hands. His entire abdomen, upper half of his
back and front of his upper legs sustained deep partial-thickness burns.
Patient was transported to small community hospital where two IV lines were started; a
Foley catheter and NG tube were inserted, and humidified O2 at 3L/min via NC. He was
given mannitol 12.5g IV before being transported to a major burn center. VS pretransport were as follows:
BP- 136/84 mm Hg
HR-96 bpm
Resp-24/min
Temp 37.2 º C (oral)
Pre-burn weight was 72 kg (160lb). He was received in the burn unit approximately 4
hours after sustaining burn injury. At admission to the unit, patient was alert and oriented
and VS were:
BP- 140/90 mm Hg
HR- 110 bpm
Resp- 24/min
Temp- 36.1 º C (oral)
Lungs sounds clear in all fields on auscultation with an occasional productive cough of a
small amount of carbon-tinged sputum. Voice was becoming hoarse. Absent bowel
sounds with NG tube draining dark yellow-green liquid. Peripheral pulses were obtained
with Doppler as they could not be palpated manually. Foley catheter draining burgundycolored urine. Urine output total since insertion 4 hours ago =280ml. Fluid resuscitation
efforts since the burn injury included 4L of lactated Ringer’s solution through the IV
lines.
Labs as follows:
CBC----WBC- 12
RBC- 3.48
Hgb-12.8
Hct 52%
ABGs on 3L O2----pH 7.37
PCO2-35
PO2-105
HCO3-18
SPO2-99%
BMP---Na+- 151
K+-5.2
Cl-112
BUN 22
Creat 1.6
Additional labs:
Myoglobin 90ng/ml
Carboxyhemoglobin 6%
UA---Specific gravity 1.040
Glucose +1
Ketones-trace
Blood-trace
Protein-trace
Burn unit MD performed fiberoptic bronchoscopy, which revealed minimal redness of
the glottis and no edema. Esharotomies were performed on bilat arms immediately after
the admission to the burn unit. Patient was bathed and scalp shaved. Burns were dressed
in occlusive silver sulfadiazine (Slivadene) dressings. Burns were then dressed twice a
day with this medication. The following regimen was prescribed: Zantac 150 mg IV
push q12h; antacid 30mlevery hour instilled via NG tube and clamped for 15minutes for
the first 48 hours after the burn; morphine sulfate 3 mg IV push every hour as needed for
pain.
Bowel sounds returned on day 3, NG tube was removed and high-calorie, high-protein
diet was begun. On day 5 of hospital stay, patient was taken to surgery for the first of a
series of surgical procedures to excise and graft the areas of full-thickness injury with
split-thickness autografts. Donor sites included his buttocks and backs of his legs.
Patient was dc’ed from hospital after a 65 day hospital stay with follow-up and rehab
scheduled.
1) Discuss the patho of burns, including the classification of burn depth and severity
of burn injury
Burn injury is the result of heat transfer from one site to another. Tissue
destruction results from coagulation, protein and denaturation or ionization of
cellular contents. The skin and mucosa of the upper airways are sites of tissue
destructions. The depth of the injury depends on the temperature of the burning
agent and the duration of contact with the agent. Burns are classified according to
the depth of tissue destruction as superficial partial-thickness injuries, deep
partial-thickness injuries or full-thickness injuries. These categories are similar to
first, second, third degree burns. Burn depth determines whether epitheliazation
will occur. Determining burn depth can be difficult. The following factors are
considered in determining the depth of a burn: how the injury occurred, causative
agent, temp of the burning agent, duration of contact with the agent and thickness
of the skin.
2) Using the rule of nines, calculate the percentage of TBSA (total body surface
area) burned. Based on TBSA, percentage and depth of bur, how would you
classify this patient’s burn?
Patient sustained full-thickness burns over the upper half of his chest (9%) and
circumferential burns to bilateral arms (18%) Patient also sustained superficial
partial- thickness burns to face, neck and bilateral hands (9%) His entire
abdomen (9%), upper half of his back (9%) and front of his upper legs (9%)
sustained deep partial-thickness burns.
TBSA = 63%- add 2% for patient neck=65%-mc
I would classify this patient as having third degree burns due to the extent of the
burns he received having been in a chemical fire. In a third degree burn, the
epidermis, entire dermis, and sometimes subcutaneous tissue; may involve
connective tissue, muscle and bone.
3) Describe the initial assessment and stabilization of a burn victim at the scene of
injury and the ED.
Preventing injury to the rescuer is the first priority of on-the-scene care. Rescue
workers cover the wound, establish an airway, supply oxygen and insert at least
one large-bore IV. A primary survey of the patient is carried out - ABC's. The
circulatory system must be assessed quickly. Apical pulse and BP are monitored
frequently. Tachycardia and slight hypotension are expected soon after the burn.
Neurologic status is assessed quickly in patients with extensive burns. No food or
fluid is given by mouth, and the patient is placed in a position that will prevent
aspiration of vomitus, because nausea and vomiting typically occur due to
paralytic ileus resulting from stress of the injury.
4) Describe the three phases of burn physiology, including a discussion of the effects
on the following systems during the emergent and acute phases: CV, respiratory,
immune system, gastrohepatic, GU and neuro
The three phases of burn physiology are Emergent/Resuscitative Phase,
acute/intermediate phase, and the rehabilitation phase.
The emergent/resuscitative phase is from the onset of injury to the completion of
fluid resuscitation. The acute/intermediate phase is from the beginning of diuresis
to near completion of wound closure. The rehabilitation phase is from major
wound closure to return to individual's optimal level of physical and psychosocial
adjustment.
CV alterations: Hypovolemia is the immediate consequent of fluid loss and results
in decreased perfusion and oxygen delivery. Cardiac output decreases before any
change in blood volume is evident. As fluid loss continues and vascular volume
decreases, CO continues to decrease and the BP drops. Abnormalities in
coagulation, including thrombocytopenia and prolonged clotting and PT times
may also occur.
Respiratory: Approx 10-20% of burn patients have an inhalation injury.
Bronchoconstriction and chest constriction can cause deterioration. Pulmonary
injuries are categorized as upper airway injury or inhalation injury below the
glottis. Upper airway injury results from inhalation of direct heat greater than 150
degrees to the epithelium. This damage results in sever upper airway edema,
which can cause obstruction of the upper airway, including the pharynx and
larynx. Indicators of possible upper airway injury include injury occurring in an
enclosed space, burns of the face or neck, singed nasal hair, hoarseness, highpitched voice change, dry cough, stridor, bloody sputum, labored breathing,
tachypnea, erythema and blistering of the oral or pharyngeal mucosa.
Immune System: Patients with burn injury are at high risk for infection and sepsis.
The skin is the largest barrier to infection, and when it is compromised, the patient
is continually exposed to the environment. The major cause of death in a burn
patient who survives after 24 hours is multiple organ dysfunction syndrome.
Gastrointestinal: Two potential GI complications may occur: paralytic ileus and
Curling's ulcer. Decreased peristalsis and bowel sounds are manifestations of
paralytic ileus resulting from burn trauma. Gastric distention and nausea may lead
to vomiting unless gastric decompression is initiated. Other alterations included
the mucosal barrier becomes permeable, the permeability allows for overgrowth
of GI bacteria, and the bacteria translocate to other organs, causing infections.
Patients are also at risk for ACS.
Renal: Renal function may be altered as a result of decreased blood volume.
Destructions of RBCs at the injury site results in free Hgb in the urine. If muscle
damage occurs, myoglobin is released from the muscle cells and excreted by the
kidneys. Adequate fluid volume replacement restores renal blood flow, increasing
the glomerular filtration rate and urine volume.
5) What significance, if any, would mannitol have on fluid resuscitation?
Mannitol is a hypertonic solution. One fluid replacement method requires
hypertonic electrolyte solutions. The goal is to deliver smaller amounts of fluid
and maintain the same urine output. Hypertonic resuscitation increases the
osmolarity of the blood and encourages shift of fluid into the intravascular space
from the interstitial space. Careful monitoring of serum sodium level is required
to prevent hypernatremia and acute renal failure. Good! mc
6) What assessment findings would indicate myoglobinuria? Describe the treatment
protocol for this condition.
Assessment findings would be that this patient had trace protein in the urine and a
Myoglobin 90ng/ml. Myoglobin is muscle protein. All patients with suspected
myoglobinuria should be admitted for IV hydration and management of
complications. A CK level of more than 5000 U/L is considered to be an absolute
indication for hospitalization and vigorous IV hydration. Initial treatment focuses
on preventing myoglobin precipitation in the urine by inducing and maintaining a
brisk diuresis. Immediately administer saline to patients with suspected
myoglobinuria because early hydration is the key to ameliorate acute kidney
injury. Isotonic saline boluses of 20 mL/kg should be initially administered, with
repeat boluses depending on the hydration status of the patient. This should be
followed by continued hydration with IV fluids given at a rate of 2-3 times
maintenance. Follow-up with mannitol to induce diuresis, supported by adequate
IV fluids, has been advocated. Mannitol causes diuresis, which minimizes
intratubular myoglobin deposition, acts as a free radical scavenger and reduces
tubule cell damage, and may act as a direct renal vasodilator.
7) What assessment findings are critical in establishing the presence of an inhalation
injury? Which assessment findings warrant concern?
Common signs of significant smoke inhalation injury are persistent cough, stridor
or wheezing; hoarseness; deep facial or circumferential neck burns; nares with
inflammation or singed hair; carbonaceous sputum or burnt matter in the mouth or
nose; blistering or edema of the oropharynxl depressed mental status; hypoxia or
hypercapnia; Carbonaceous sputum or burnt matter in the mouth or nose; elevated
carbon monoxide and/or cyanide levels.
Injury from the inhalation of hot gases generally occurs above the vocal cords and
can cause significant edema.
This patient had occasional productive cough of a small amount of carbon-tinged
sputum. Voice was becoming hoarse. Burn unit MD performed fiberoptic
bronchoscopy, which revealed minimal redness of the glottis and no edema.
8) Describe the treatment protocol for a patient with an inhalation injury or
suspected inhalation injury.
Treatment usually consists of early intubation and mechanical ventilation with
100% oxygen, which reduces the half-life of carboxyhemoglobin from 4 hours to
45 minutes. Restrictive pulmonary excursion may occur with full thickness burns
encircling the neck and thorax. Chest excursion may be greatly restricted,
resulting in decreased tidal volume. In some situations, escharotomy is necessary.
9) What is the purpose of escharotomies?
The need for escharotomies is relatively common in the treatment of burn injuries.
The need arises because the tight eschar may interfere with the circulation to a
limb causing demarcation and loss of the limb or in the case of the chest, may
cause interference with respiration such that the expansion in the lungs is
interfered with causing atelectasis and pneumonia. In the neck the oedema in the
tissue may cause obstruction to the trachea. Indications for escharotomy rest on
clinical grounds with tension in the limb under the burn and the state of
circulation to the periphery being important. Added to this is the use of Doppler
ultrasound, clinical presence of peripheral pulses and at times compartmental
pressure measurements. The aim of the escharotomy is to release the pressure
over the involved deeper tissues and to restore their circulation.
10) Discuss pain management in the treatment protocol for the patient with a burn
injury.
The pharmacologic treatment for the management of burn pain includes the use of
opioids, NSAIDs, anxiolytics, and anesthetic agents. Treatment of anxiety with
benzodiazepines is used along with opioids to achieve both a pain free and
anxiety free experience.
Nonpharmalogic pain control can be achieved by using relaxation techniques,
distraction, guided imagery, hypnosis, therapeutic touch, humor, music therapy
and more recently virtual reality techniques.
11) Discuss burn wound care and dressing techniques. Include the types of topical
antimicrobial agents commonly used in wound care, listing advantages and
disadvantages of each.
Various measures are used to clean the burn wound, such as hydrotherapy. If the
patient is ambulatory, the wounds can be cleansed in a shower. The wounds of a
nonambulatory patient can be cleansed using shower carts. After wound cleaning,
the burned areas are patted dry and the prescribed topical agent is applied; the
wound is then covered with several layers of dressings. A light dressing is used
over joint areas to allow for motion. A light dressing is also applied over areas for
which a splint is placed. Circumferential dressings should be applied distally to
proximally. If the hand or foot is burned, the fingers and toes should be wrapped
individually to promote adequate healing. A light dressing can be applied to the
face to absorb excess exudates that might run into the eyes. Occlusive dressings
may be used over areas with new skin grafts to protect the graft and promote an
optimal condition for its adherence to the recipient site.
Topical Antibacterial Agents used include:
Silver Sulfadiazine 1% - Most bactericidal agent; minimal penetration of
eschar.
Mafenide acetate 5% to 10% - Effective against gram-negative and grampositive organisms; diffuses rapidly through eschar; in 10% strength, it is the
agent of choice for electrical burns because of its ability to penetrate thick eschar.
Silver Nitrate 0.5% - Bacteriostatic and fungicidal; does not penetrate
eschar.
Acticoat - Effective against gram-negative and gram-positive organisms
and some yeasts and molds; delivers a uniform, antimicrobial concentration of
silver to the burn wound.
12) Discuss the use of autografts and nursing care required.
Autografts are the ideal means of covering burn wounds because the grafts are the
patient's own skin and therefore are not rejected by the patient's immune system.
They can be split-thickness, full-thickness, pedicle flaps or epithelial grafts. Fullthickness autografts and pedicle flaps are commonly used for reconstructive
surgery, which may take place months or years after the initial injury.
If blood, serum, air, fat or necrotic tissue lies between the recipient site and graft,
there may be partial or total loss of the graft. Infection or mishandling of the graft
and trauma during dressing changes account for most other instances of graft loss.
Protection if the key goal of caring for skin grafts. Occlusive dressings are
commonly used initially after grafting to immobilize the graft. The first dressing
change is to be completed 2-5 days after surgery. The patient is positioned and
turned carefully to avoid disturbing the graft or putting pressure on the graft site.
If an extremity has been grafted, it is elevated to minimize edema. The patient
begins exercising the grafted area 5-7 days after grafting.
13) Describe appropriate care for donor sites
A moist gauze dressing is applied at the time of surgery to maintain pressure and
to stop any oozing. After the donor site is excised, a thrombostatic agent such as
thrombin or epi may be applied directly to the site. The donor site may be covered
in several ways, from single layer gauze impregnated with pertolatum, scarlet red,
or bismuth to new biosynthetic dressings such as Biobrane or BCG Matrix.
Acticoat can also be used as a dressing on donor sites. With all types of covering,
donor sites must remain clean, dry and free from pressure.
14) List nursing diagnoses, outcomes, and interventions appropriate for the care of
the patient with a burn injury during the emergent and acute phases of burn
physiology
Impaired gas exchange RT carbon monoxide poisoning, smoke inhalation and
upper airway obstruction:
Outcome - absence of dyspnea, resp rate between 12-20, lungs clear on
auscultation, O2 sats greater than 96%, ABGs within normal limits.
Interventions - Provide humidified O2, assess breath sounds and resp rate,
monitor ABGs, prepare for intubation
Ineffective airway clearance RT edema and effects of smoke inhalation:
Outcomes - patent airway, minimal resp secretions, normal resp rate,
pattern and breath sounds.
Interventions - maintain patent airway, provide humidified O2, encourage
patient to turn, cough and deep breathe.
Fluid volume deficit RT increased capillary permeability and evaporative losses
from the burn wound:
Outcome - serum electrolytes within normal limits, urine output between
0.5 - 1.0 mL/kg/hr, BP greater than 90/60, heart rate less than 120 bpm,
exhibits clear sensorium, voids clear yellow urine.
Interventions - observe vital signs and urine output, monitor urine output
hourly, weigh patient daily, be alert for signs of hypovolemia or fluid
overload
Hypothermia RT loss of skin microcirculation and open wounds:
Outcome - Body temp remains 97-101degrees F, absence of chills or
shivering.
Interventions - provide a warm environment, work quickly when wounds
must be exposed, assess core body temp frequently.
Pain RT tissue and nerve injury and emotional impact of injury:
Outcome - states pain level is decreased, absence of nonverbal cues of
pain.
Interventions - pain level provides baseline for evaluating effectiveness of
pain relief measures, IV administration is necessary because of altered
tissue perfusion from burn injury, emotional support is essential to reduce
fear and anxiety.
Anxiety RT fear and the emotional impact of burn injury:
Outcome - patient and family verbalize understanding of emergent burn
care, able to answer simple questions
Interventions - assess patient and family's understanding of burn injury,
explain all procedures in clear terms, maintain adequate pain relief,
administer prescribed anti-anxiety meds
15) Discuss the psychosocial aspects of caring for a patient with a burn injury and the
impact on the patient’s support system.
Psychological treatment plans should include a full assessment of patient issues
and a targeted plan with the appropriate resources to promote the patient's social
and vocational reintegration and improved quality of life. Burn injuries can have a
major impact on quality of life. Changes in physical activity as well as social and
psychological adjustments, such as returning to school and employment status,
may be challenging. It is important throughout this process to assess and address
the family needs. When one member of a family sustains a major burn injury, the
entire family is affected. Separation, feelings of helplessness, loss and
psychological dysfunction may be experienced in varying degrees. Family and
friends need support, education, and guidance in assisting the patient to return to
their optimal health.
EXCELLENT! mc/Marianne Clouston MSN, RN 040813