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.