This PowerPoint file is a supplement to the video
presentation. Some of the educational content of
this program is not available solely through the
PowerPoint file. Participants should use all
materials to enhance the value of this continuing
education program.
EMS/Nursing
81212/
39112
Burns: Part 2
Toni Galvan, MSN, RN, CCRN, CEN
Charge Nurse II
Medical Intensive Care Unit
Covenant Health System
Lubbock, Texas
EMS/Nursing
81212/
39112
Objectives
1. Identify risks to burn
patients related to
compartment
syndromes.
EMS/Nursing
81212/
39112
Objectives
2. Recognize effective
methods in wound
care for burn patients.
EMS/Nursing
81212/
39112
Objectives
3. Recognize elements of
a regimen for
successful wound
healing.
Complications:
Peripheral Ischemia
rd
 Risk: usually 3 degree
circumferential burns and
electrical burns leading to
compartment syndrome
(edema and pressure in
fascial compartment)
Complications:
Peripheral Ischemia
 Assess for: pain, pallor,
pulselessness, paresthesia,
paralysis, poikilothermia
(6 Ps)
 Doppler pulses: palmar arch,
finger webs
Circumferential
burn – checking
pulses
Treatment Compartment
Syndrome
 Continue pulse check
 Elevate extremity to level of
heart
 Consider escharotomy:
cutting through eschar
Escharotomy Locations
Escharotomy Locations
 Also vertical cuts on lateral
neck, avoiding great vessels
and trachea
 What about pain?
 What about scars?
Escharotomies
improperly done→
3rd degree burn in
Caucasian child
Inhalation Injury
 Inhale hot air, steam, smoke,
carbon monoxide (CO)
 Above glottis: actual burn,
compromise to airway
Inhalation Injury
 Below glottis: toxic effects
similar to acquired
respiratory distress
syndrome (ARDS)
Inhalation Injury
 Suspect if:
 face and/or neck burns
 singed nose hairs
 flame burn in enclosed
spaces
 carbonaceous sputum
Inhalation Injury
 Suspect if:
 early edema of tongue
 burns of nasal or oral
mucosa
Inhalation Injury
 Early signs and symptoms
 hoarseness and drooling
(#1)
Inhalation Injury
 Early signs and symptoms
 altered ABGs (arterial
blood gas), especially
hemoglobin CO (HbCO) 2060%
Inhalation Injury
 DO NOT use pulse oximetry
(SpO2) to monitor O2
saturation
Inhalation Injury
 Treatment: early intubation
and ventilation with
fractional inspired oxygen
(FiO2) 1.0 and added
pressure or high frequency
ventilation (HFV)
Wound Care
 Keep very clean: scrub
 Grafts
 only autograft, cultured
epidermis, and isograft
(identical twin) are
permanent
Wound Care
 Keep very clean: scrub
 Grafts
 others are temporary to
encourage capillary neogenesis in wound bed and
act as wound dressing
Goals of Wound Care
 Close wound as soon as
possible – preserves
cosmetics (looks) and
function
 Optimal closure – prevents
infection
Goals of Wound Care
 Early care of deep burns –
encourages rapid
granulation and preparation
for grafting
 Medicate for pain prior to
wound care
Wound Assessment and
Documentation
 Location
 Size, depth
 Color, texture, sensation
 Odor
Wound Assessment and
Documentation
 Exudate color, amount,
quality
 Exposed bone, tendon,
cartilage, subcutaneous
tissue
Wound Assessment and
Documentation
 Surrounding tissue
inflammation/infection
Early Wound Care for
Heat Burns
 Remove patient from site
 Remove clothing and
jewelry, especially
circumferential
Early Wound Care for
Heat Burns
 Cool wound with, ideally,
cool sterile saline – use tap
water or whatever else is
available if necessary
Early Wound Care for
Heat Burns
 DO NOT apply topicals until
after initial assessment and
determination of minor/
moderate/major and depth of
wounds
Treatment for First
Degree
 Keep clean: soap and tepid
water
 Apply moisturizer such as
®
Aquaphor , aloe vera gel
Treatment for First
Degree
®
 Use Tylenol for pain
 Key: prevention
Treatment for Second
Degree/Partial-thickness
 Débride blisters and loose
(dead) skin
Treatment for Second
Degree/Partial-thickness
 Clean: scrub with surgical
sponges (sterile) or very
clean technique (clean
washcloth, shower or clean
washbasin, new mild soap)
Treatment for Second
Degree/Partial-thickness
 Dressings
®
 Biobrane for clean wounds
without topical residues of
any kind – replace every 2 to
3 days or as instructed
Treatment for Second
Degree/Partial-thickness
 Aquaphor®, if very shallow,
for each cleaning
Treatment for Second
Degree/Partial-thickness
 Triple antibiotic ointment if
inflammation
 NEVER use on cartilage
 cover with non-adherent
dressing
Topical Meds
®
 Aquaphor : water soluble
moisturizer
 Aloe vera gel: herbal, water
soluble moisturizer
Topical Meds
 Triple antibiotic ointment:
can be nephrotoxic if used
for >20% TBSA [total body
surface area (covered)]
Topical Meds
®
 Sulfamylon (mafenide
acetate)
 painful, can be
nephrotoxic, cause
metabolic acidosis
Topical Meds
®
 Sulfamylon (mafenide
acetate)
 used on deep burns, thick
eschar, pseudomonas
infection
Topical Meds
®
 Silvadene (silver
sulfadiazine)
 less painful and minimal
systemic absorption
 softens eschar and retards
bacterial growth
Topical Meds
®
 Silvadene (silver
sulfadiazine)
 can suppress white blood
cells (WBCs)
 Nystatin: for yeast
Topical Meds
 Furacin: used for resistant
staph and strep infections
 Acticoat™ silver dressing
 antimicrobial
 keep moist with sterile
water
Topical Meds
 Furacin: used for resistant
staph and strep infections
 Acticoat™ silver dressing
 wounds will be stained
Topical Meds
®
 Aquacoat
 impregnated with
Silvadene® and activated
with sterile water
 sustained release
Topical Meds
 Accuzyme™: dissolves
eschar, dead tissue
 Bactroban®: effective against
gram+ staph and strep
Topical Meds
 Scarlet Red
 tincture of mercury
 used on donor sites and
very shallow 2nd degree
 antimicrobial and
stimulates granulation/
healing
Topical Meds and
Dressings
 Choice of topicals by type of
wound and if infected
 Generally prescribed
Topical Meds and
Dressings
 Precise wound care
instructions post-burn unit
prescribed, taught to family
or home health staff
 Questions: call BICU (burn
intensive care unit)
Grafts
 Allograft/homograft
 human cadaver
 used as temporary
dressing to promote
granulation
Grafts
 Xenograft/heterograft
 pig skin
 used as temporary
dressing to promote
granulation
 Synthetic

Grafts
Biobrane®, SkinTemp™,
Integra™, nylon,
TransCyte®, XenoDerm
 Synthetic


Grafts
used as temporary
dressing to promote
healing or granulation
also used on autograft
donor sites
Permanent Grafts
 Autograft
 self or cultured epidermis
 used for final repair
Permanent Grafts
 Care
 pressure dressing for 3
days, undisturbed
 then, clean gently and
cover with protective
dressings until healed,
then leave open to air
Permanent Grafts
 Care
 observe closely for signs
and symptoms of infection
Graft Procedures
 Remove autograft with
dermatome
 Apply as full-thickness or
mesh
 Use
full-thickness on face,
hands, feet, genitalia unless
lack of viable skin for grafts
 Meshed
skin: stretches to
cover more area and is used
on trunk, limbs
Mesh graft of hand
Mesh graft with wound
drain space
Full-thickness
graft of hand
Cultured epithelial tissue
after placement
Post-graft Care
 Donor site care: Scarlet Red
or Aquaphor® or other
moisturizer and transparent
dressings
Care of Temporary
Grafts
 Cadaver skin and pig skin
 change about every 3 days
or if evidence of infection
 cover with pressure
dressings often
Care of Temporary
Grafts
 Synthetic
 change every 3-14 days
(manufacturer
instructions)
 can be left open or covered
Care of Temporary
Grafts
 Synthetic
 most cannot be used on
eschar, must débride first
Support of Wound
Healing
®
 Oxandrin
 promotes use of dietary
protein
 anabolic steroid
 controlled drug
Support of Wound
Healing
 High-dose vitamins A and C:
wound healing
 High-dose zinc: stress,
wound healing
 General nutrition: highcalorie, high-protein diet
Patient and Family
Teaching
 Essential for recovery
 Properly done wound care
hurts – patients and families
have trouble scrubbing hard
enough
Patient and Family
Teaching
 Absolute cleanliness
essential
 First sign of infection: return
to doctor
Patient and Family
Teaching
 Nutrition and ROM (range of
motion) and general activity
essential for recovery – no
“couch potatoes”
Patient and Family
Teaching
 Use splints/pressure
garments as prescribed –
pressure garments need to
be worn at all times for
optimum effect
Infection
 Leading cause of death in
burns after first 72 hours
 Prevention: HANDWASHING
 Prevention: properly done
wound care
Signs and Symptoms of
Infection
 Persistent true fever (lowgrade fever normal in burns)
Signs and Symptoms of
Infection
 Increasing wound exudate
after 72 hours, especially
pseudomonas or staph (early
in healing, moderately thick,
yellow exudate is expected)
Signs and Symptoms of
Infection
 Cellulitis of surrounding
tissues: red, swollen, painful
 WBC changes
 Positive wound cultures
Treatment of Infection
 Systemic antibiotics by
culture results
 Appropriate topicals
Treatment of Infection
 Often necessary to return to
BICU for intravenous (IV)
antibiotics and/or surgical
débridement and regraft
 Expensive: best to prevent
Special Situations
 Tar
 immediately cool with any
liquid
 use petroleum jelly or
mineral oil to remove
 continues to burn until
removed
Special Situations
 Friction burns (road rash):
nd
treat as superficial 2
degree
Special Situations
 Eyelids, lips, and ears
require special care
®
 no Neosporin on exposed
cartilage
®
 use Neosporin on all
others
Special Situations
 Face: shave males daily
 Chemical burns: brush off
dry chemicals immediately,
remove clothing, shower or
hose quickly
Special Situations
 Chemical burns in eye:
irrigate with tap water
quickly, copiously
 Electrical burns: transport to
burn unit for all
Complication
 Keloids (scar hypertrophy):
from lack of pressure during
healing
Complication
 Contractures
Complication
 Contractures: from lack of
physiologic positioning and
lack of aggressive exercise
therapy during healing
Complication
 Myoglobinuria
 from electrical burns, large
muscle burns
 large molecules damage
renal tubules resulting in
hematuria
Complication
 Myoglobinuria
 can indicate
rhabdomyolysis
Electrical Burns
 Order current travels:
nerves, blood vessels,
muscle, bone
 Wound: entry and exit,
invisible damage between
Electrical Burns
 Complications: ventricular
fibrillation, other
dysrhythmias, respiratory
tetany and arrest, falls,
fractures
 Severity: length exposure,
voltage, concomitant injuries
Electrical Burns
 Treatment
 débride (often extensive)
 cardiac monitor
 treat dysrhythmias
 mechanical ventilator as
needed
Electrical
Burns
Entry wound
Exit wound
Chemical Burns
 Damage: strength, duration,
volume, permeability, mode
of action
 Most common: acids
Chemical Burns
 Most troublesome: alkali
because it adheres to tissue
causing protein lysis and
liquefaction
 Household chemicals:
bleach and ammonia
Chemical Burns
 Farm: organophosphates
and other fertilizers and
weed control chemicals
Chemical Burn Initial
Care
 Topical: (except sodium
metal) remove agent and
clothing, shower with tepid
tap water
Chemical Burn Initial
Care
 Eyes: irrigate with tap water
st
(1 aid) or normal saline (do
not use irrigation lenses)
Chemical Burn Initial
Care
 Inhalation (mustard gas,
etc.): 100% O2 at high
pressure/frequency
 Sodium metal explodes in air
and H2O – remove surgically
under oil
Chemical burn:
fell in vat of chemical
Phases of Care
 Emergent: 24-72 hours
 Acute: days-months (until
wounds closed)
 Rehabilitation: starts on
admission/initial treatment
and goes up to 2 years
Immediate Care
Priorities
 ABCs (airway, breathing, and
circulation): intubate as
needed
 Remove all clothing/jewelry
 Estimate size, depth
Immediate Care
Priorities
 Fluid resuscitation for burn
shock
 Evaluate for late inhalation
injury
Immediate Care
Priorities
 Peripheral circulation and
escharotomy as needed
 Pain: morphine, incremental
IV doses
 Wound care: débride, clean
Immediate Care
Priorities
 Tetanus history and
treatment
Continuing Care
 Wound care as discussed
 Keep clean
 Itch: lotion
Continuing Care
 Pain
 over-the-counter, as
Tylenol® or NSAID
(nonsteroidal antiinflammatory drugs) or PO
(oral) narcotics
Continuing Care
 Pain
 take on schedule and as
needed
 ROM, ambulation, exercise
as appropriate
Continuing Care
 Scars/keloid: use pressure
garments, splints
 Sun protection
 healed burns always more
sensitive
 avoid all sun 12-18 months
Lifestyle
 Return to work when initial
healing and energy level
adequate – no sun exposure
 Nightmares and PTSD (posttraumatic stress disorder):
treat – these are real
Lifestyle
 Depression and fatigue
 part of healing
 some require treatment
 rest more
 talk about it
 family teaching/support
Lifestyle
 Scars



many are permanent
body image disturbance
some color change
Rehabilitation
 Starts on admission/initial
treatment
 Range of motion and activity
 Pressure garments and
splints
Rehabilitation
 Medical follow-up (burn
clinic)
 Lifestyle adjustments
 Return to productivity
How long to heal?
 Complete maturity: 1-3 years
 Some need further surgery
to improve cosmetics during
first year
 Initial closure: weeks to
months for large deep burns;
if infected, takes longer
Other Complications of
Burns
 Death
 Functional long-term
disability
Other Complications of
Burns
 Financial and role stress
 patient
 family/significant others
 community
Transport
 Contract with tertiary site
 Transport major and some
moderate
 MD-MD and RN-RN contact
as early as possible and
update on dispatch
Transport
 Choose method of transport:
ground or air
 Stabilize for transport
Stabilize for Transport
 Airway
 if in doubt, intubate
 always intubate anyone
with possible inhalation
injury
Stabilize for Transport
 Fluids
 stable IV sites and initial
fluid resuscitation started
 Foley catheter inserted
Stabilize for Transport
 Wounds
 remove clothing and
jewelry
 cover wounds loosely with
dry, non-adherent
dressings
Stabilize for Transport
 Pain: narcotic coverage
 Family: instructions to find
agency and NO SPEEDING
Documentation for
Transport
 Copy all lab/x-rays
 What was done for wounds
 Fluid resuscitation with
times
 Next of kin/family
location/contact
Documentation for
Transport
 Miscellaneous
Summary
 Large burns are devastating
for victim and family
 Most are preventable
 Mortality rate diminishing
with proper early care
Summary
 Long-term disability not
necessary for most with
proper care
EMS/Nursing
81212/
39112
Burns: Part 2
If you have any questions about the program
you have just watched, you may call us at:
(800) 424-4888 or fax (806) 743-2233.
Direct your inquiries to Customer Service.
Be sure to include the program number, title
and speaker.
EMS/Nursing
81212/
39112
Release Date:
04/01/2012
The accreditation for this
program can be found by
signing in to
www.ttuhsc.edu/health.edu
EMS
81212
This continuing education activity is approved by the
Continuing Education Coordinating Board for
Emergency Medical Services for 1.5 advanced CEH.
You have participated in a continuing education
program that has received CECBEMS approval for
continuing education credit. If you have any
comments regarding the quality of this program
and/or your satisfaction with it, please contact
CECBEMS at: CECBEMS -12200 Ford Road, Suite
478
Dallas, TX 75234 Phone: 972-247-4442 lsibley@cecbems.com
Nursing
39112
The Texas Tech University Health Sciences Center Continuing
Nursing Education Program is accredited as a provider of continuing
nursing education by the American Nurses Credentialing Center's
Commission on Accreditation.
Provider approved by California Board of Registered Nursing,
Provider #CEP11800, for the designated number of contact hours for
each program. Provider approved by Florida Department of Health
Board of Nursing, Provider #FBN2060. Provider approved by West
Virginia Board of Examiners for Registered Professional Nurses,
Provider #WV1998-0262RN. Iowa Board of Nursing approved provider
#325. Accepted by the North Carolina Board of Nursing. Reminder to
all PARTICIPANTS, certificates should be retained for a period of four
(4) years.
Health.edu reports Florida Continuing Education (Contact Hours) to
CE Broker. This activity provides 1.5 contact hours.
Nursing
39112
This activity is presented for educational
purposes only. Participants are expected to
utilize their own expertise and judgment while
engaged in the practice of nursing. The content
of the presentations is provided solely by
presenters who have been selected for
presentations because of recognized expertise
in their field.
Nursing
39112
DISCLOSURE TO PARTICIPANTS
Requirements of successful course completion:
•Complete the program via video presentation, PowerPoint
slides, audio presentation, and/or manuscript.
•Complete the course evaluation.
•Complete the posttest with a score of 80% or greater.
•Complete the time utilized in course completion including
the posttest.
Nursing
39112
Conflicts of Interest:
Toni Galvan, MSN, RN, CCRN, CEN has disclosed that no financial interests,
arrangements or affiliations with organization/s that could be perceived as a
real or apparent conflict of interest in employment, leadership positions,
research funding, paid consultants or member of an advisory board or
review panel, speaker’s bureau, major stock or investment holder, or other
remuneration.
Commercial Support:
There is no commercial support and/or relevant financial relationships
related to this educational activity. Commercial support is defined as
financial (or in-kind) contributions given by a commercial interest, which is
used to pay all or part of the costs of a CNE activity. Relevant financial
relationships are defined as financial relationships of any amount,
occurring within the past 12 months, including financial relationships of a
spouse or life partner that could create a conflict of interest.
Nursing
39112
Non-endorsement of Products:
Toni Galvan, MSN, RN, CCRN, CEN has disclosed that no
significant relationships with commercial companies whose
products or services are discussed in educational presentations.
For speakers, significant relationships include receiving from a
commercial company research grants, consultancies, honoraria
and travel, or other benefits or having a self-managed equity
interest in a company. Disclosure of a relationship is not intended
to suggest or condone bias in any presentation, but is made to
provide participants with information that might be of potential
importance to their evaluation of a presentation.
Off-label Use:
Toni Galvan, MSN, RN, CCRN, CEN has disclosed that no products
with off-label or unapproved uses are discussed within this activity.
Nursing
39112
Individual programs are provided for a two (2) year period.
Participants should check with their site coordinator, sign in
to Health.edu’s internet site,
http://www.ttuhsc.edu/health.edu or call Education Services
at 1-800-424-4888 for information on the date through which
this learning activity is provided. For questions or
comments regarding accreditation, please call Education
Services at 1-800-424-4888.To speak to a Customer Service
representative, please call 1-800-424-4888.
Institutional refund is available to subscribing organizations
according to Health.edu’s tuition refund policy. See your
site coordinator to view this program.