Transcript Burnsx

BURNS
Kelsey Pfeiffenberger
Non-complex Burns


Previously described as minor burns
Any partial thickness thermal burn covering ≤15% total
body surface area (TBSA) in adults or ≤10% in children
(≤5% in children younger than 1 year) that does not
affect a critical area


Critical areas include burns on the hands, feet, face,
perineum or genitals, burns crossing joints, and
circumferential burns
Also includes deep dermal burns covering ≤1% of the
body
How to determine TBSA



Lund and Browder Chart
“Rule of Nines”
Palmar surface
http://www.uwhealth.org/emergency-room/assessingburns-and-planning-resuscitation-the-rule-of-nines/12698
http://uhealthsystem.com/health-library/derm/anatomy
Definitions of Burn Depth

Superficial partial thickness burns:
 First
degree :
 Superficial
 Second
burns affect only the epidermis
degree:
 Superficial
dermal burns extend into the upper layers of the
dermis
 Deep dermal burns extend into the deeper layers of the
dermis but not into the subcutaneous tissue

Full thickness burns:
 Third
and fourth degree burns may extend into the
muscle and bone
Pathophysiology





All burn injuries cause a local response consisting of
inflammation, regeneration, and repair
In superficial areas and around the edges, ingrowth of
capillaries and fibroblasts, followed by formation of
granulation tissue and scarring occurs during the repair
process
Zone of coagulation/necrosis
Zone of stasis
Zone of hyperaemia
Assessment

Primary Survey
 Airway
maintenance with cervical spine control
 Breathing and ventilation
 Circulation with hemorrhage control
 Disability (neurological assessment)
 Exposure (preventing hypothermia)
 Fluid resuscitation
In patients who are clearly well, other than the noncomplex burn, it is acceptable to move straight to the
Secondary Survey

Secondary Survey
 Consists
of the patient history and the physical
examination of the burn
 Identifies issues that could impact the management of
the patient or implications for transfer
When to refer

Criteria for referring patients with complex wounds to specialized
burn units includes:






>10% total body surface area in children and >15% in adults
All full thickness burns, deep dermal burns >5% in adults and all deep
dermal burns in children
Chemical or electrical burns
Burns on the face, hands, genitals, perineum, or large joints,
circumferential deep burns, inhalation injury, associated injuries, and
septic burn wounds
A non-complex burn that has not healed within 2 weeks should be
referred to a burn surgeon for possible excision and grafting
If non-accidental injury is suspected in children, immediate hospital
admission is required regardless of the degree of the burn
Mechanisms of injury





Thermal mechanisms
Electrical burns
Chemical burns
Sun burn
Children, elderly, those with reduced mental capacity,
reduced mobility, or sensory impairment are at an
increased risk of burn injury
Patient History

HPI
 Mechanism
 What
of injury
was the exact cause?
 When did it occur?
 How did it come into contact with the patient?
 For how long was the patient exposed to the injuring agent?
 Was any first aid performed?
 Depending on the cause, you would want to ask more
specific questions related to the injuring agent
Patient History

Medical history


Past and current medical problems
Medications


Vaccinations







Photosensitizing medications: thiazide diuretics, sulfa-containing agents,
tetracyclines such as doxycycline, griseofulvin, phenothiazines, nalidixic acid,
and St. John’s wort
Tetanus (vaccine should be administered if one was not received within the
last 5 years)
Nutrition status
Allergies
Smoking and alcohol use
Abuse
Possible pregnancy
A thorough history could provide clues as to why the injury occurred
and what may be needed in the treatment plan
Clinical Manifestations

First degree burns



Superficial dermal burns



Painful red blisters or broken epidermis with a weeping surface
Most common causes: scalds or brief exposure to a flame
Deep dermal burns



Painful, red, blanches with pressure, and swollen
Most common causes: ultraviolet radiation, scalding, low-intensity steam
exposure, and brief contact with a hot object
Dry and blotchy or mottled with a cherry red stained appearance
Blanching with pressure does not occur and sensation is variable
Superficial burns can be extremely painful compared to deep burns
because the nerve endings remain intact and exposed
www.woundsinternational.com
http://www.burn-recovery.org/injuries.htm
Diagnosis

Primarily diagnosed from the patient history and
physical examination
Diagnostic Tests



There are no diagnostic tests for burns
If there is a concern about infection, a procalcitonin
(PCT) level can be ordered
A PCT of 0.56 ng/mL has a sensitivity of 75% and a
specificity of 80% when compared with quantitative
swab culture; however, this is not considered diagnostic
but it should prompt the provider to look for a possible
cause for the infection

Most burn wound infections are caused by methicillinresistant Staphylococcus aureus, Acinetobacter baumanniicalcoaceticus complex, Pseudomonas aeruginosa, and
Klebsiella species
Differential Diagnoses and Red Flags

Cellulitis



Toxic epidermal necrolysis




Characterized by pain, swelling, redness, and warmth
Usually caused by an acute infection from a cut, laceration, or
fissure
Characterized by widespread erythema and bullous detachment
of the epidermis and mucous membranes
Affects more than 30% of the body surface area
Most commonly caused by medications
Stevens-Johnson syndrome



Less severe than TEN
Affects less than 10% of the body surface areas
Most commonly caused by medications
Prognosis




Depends on the extent of the tissue damage,
comorbidities, associated injuries, or complications
Complications include sepsis, gangrene, or
neurologic, cardiac, cognitive, or psychiatric
dysfunction
Superficial and superficial dermal wounds usually
heal within 1 week
Dermal burns may take up to 2 to 3 weeks to heal
First Aid

Cool the burn with running water between 12o and 18oC
within 20 minutes after the injury




Should be continued for up to 30 minutes
Can also use a wet compress
Applying ice is not recommended because it can cause
vasoconstriction
Burns should be covered immediately after cooling to
prevent bacterial colonization, dessication, and relieve pain
from exposed nerve endings


Polyvinylchloride film, such as cling film, Glad wrap, or Saran
wrap, makes excellent dressings in emergency situations
In hot or humid climates, dressings become rapidly saturated and
wounds should be left exposed or loosely covered
Treatment



Treatment aims at reducing inflammation,
preventing infection, relieving pain, and promoting
healing
Irrigate with normal saline or warm tap water to
remove foreign bodies, soluble debris, or necrotic
tissue
Blisters should only be removed if they are greater
than 1 cm; if they are smaller they should be left
intact
Treatment: Dressings



Dressings should maintain a moist environment, contour
easily, be non-adherent, retain close contact to the
wound, easy to apply and remove, painless, protect
against infection, and be cost-effective
The first dressing change should be 48 hours after the
injury then every 3 to 5 days after
Practice guidelines suggest dressing selections based on
the extent of injury

Superficial epidermal burns


Soothing gels such as aloe vera or moisturizing cream
Superficial dermal burns and deep dermal burns: the
dressing depends on the amount of exudate

Foams, alginates, hydrocolloids, hydrogels, and honey dressings
can be used
www.woundsinternational.com
Treatment: Antimicrobials

Topical antimicrobials can be used to prevent
infection in second degree burns


Oral antimicrobials are not recommended for prevention
Silver sulfadiazine (SSD) cream
Broad-spectrum
 Can be applied as a thick layer but needs to be washed
off and redressed daily

Treatment study

Open dressings with petroleum gel (Vaseline) vs.
standard gauze silver sulfadiazine dressings in minor
superficial partial thickness burns
Petroleum gel may be as effective as silver sulfadiazine in
regard to re-epithelialization and incidence of infection
 Open dressings with petroleum gel was superior to silver
sulfadiazine in ease of removal, adherence to the wound
bed, and time required to change the dressings
 Petroleum gel costs $7 and silver sulfadiazine (Flamazine)
costs more than $60 excluding the gauze

Pain Management



Non-steroidal anti-inflammatory drugs or aspirin
should be the first choice
Weak opioids such as codeine can be used for mild to
moderate pain
Topical corticosteroids can be applied for
symptomatic relief in extensive sun burn
Education


Nutrition
Skin care
Signs of infection
 Sunscreen and avoiding direct sun exposure
 Non-perfumed moisturizers


Burn prevention at home
Questions?
References
Atiyeh, B., Barret, J. P., Dahai, H., Duteille, F., Fowler, A., Enoch, S., . . . Zhao-fan, X. (2014)
International best practice guidelines: Effective skin and wound management of
noncomplex burns. Retrieved from www.woundsinternational.com
Cohen, V. (2015, October 21). Toxic Epidermal Necrolysis. Retrieved from http://emedicine.medscape.com
Edlich, R. F. (2015, September 1). Thermal Burns. Retrieved from http://emedicine.medscape.com
Genuino, G. A. S., Baluyut-Angeles, K. V., Espiritu, A. P. T., Lapitan, M. C. M., & Buckley, B.
S. (2014, November 1) Topical petrolatum gel alone versus topical silver sulfadiazine
with standard gauze dressings for the treatment of superficial partial thickness burns in
adults: A randomized controlled trial. Burns, 40 (7), 1267-1273. Retrieved from
www.elsevier.com
Goroll, A. H. & Mulley, A. G. (2014). Primary care medicine: Office evaluation and
management of the adult patient (7th ed.). Philadelphia, PA: Lippincott Williams
Wilkins.
Hospenthal, D. R. (2014, August 27). Burn Wound Infections. Retrieved from
http://emedicine.medscape.com
Papadakis, M. A. & McPhee, S. J. (2016). Current medical diagnoses & treatment (55th ed.). New York, NY:
McGraw-Hill Education.