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Ch 25 – Phases of Burn Management

3 stages
emergent – resuscitative
acute – wound healing
rehabilitative – restorative
primary focus in acute phase
wound care
but also takes place in emergent & rehabilitative phases
prehospital care – priority given to
removing person from source of burn
stopping burning process
rescuers must protect from injury
prehospital care – electrical injuries – initial managment
removal of patient from contact of electrical source
prehospital care – small thermal burns (=<10%TBSA) - care
covered with clean, cool, tap water-dampened towel
ensures comfort/protection until medical care
helps minimize depth of injury
cooling injured area (if small) within 1 minute
larger burns >10% TBSA or electrical or inhalation burn
attention on ABCs
ABCs – Airway
check for patency
soot around nares/on the tongue
singed nasal hair
darkened oral or nasal membranes
ABCs – Breathing
check for adequacy of ventilation
ABCs – Circulation
check for presence and regularity of pulses
elevate burned limbs above heart to decrease pain & swelling
preventing hypothermia
large burns cooled for no more than 10 minutes
to prevent extensive heat loss
do not immerse burned body part in cool water
hypothermia & vasoconstriction of blood vessels occurs when
covering a burn with ice
result of covering a burn with ice
reduces blood flow to injury
to prevent further tissue damage
gently remove as much burned clothing as possible
adherent clothing should be left in place until in hospital
to prevent further contamination of wound & provide warmth
wrap in dry, clean sheet or blanket
chemical burns – best treated
removing the solid particles from skin
any clothing containing chemical removed to stop continuation of burning process
flushed with alot of water irrigate skin anywhere from 20 min to 2 hours postexposure
tap water acceptable for flushing eyes exposed to chemicals
chemical burn – tissue damage how long
can continue for up to 72 hours after chemical burn
inhalation agents observe for
signs of respiratory distress or compromise
need to treat quickly & efficiently at scene for survival
if CO intoxication suspected – 100% humidified O2
both body burns & inhalation injuries – where to transfer
nearest burn center
emergent phase – other name
resuscitative phase
emergent phase – define
period of time required to resolve the immediate, life-threatening problems resulting from burns
emergent phase – timeframe
lasts up to 72 hours from time of burn
emergent phase – primary concerns
onset of hypovolemic shock & edema formation
emergent phase – phase ends when
fluid mobilization & diuresis begins
emergent phase – patho – F&E shifts – greatest threat to patient with major burn
hypovolemic shock
emergent phase – patho – F&E shifts – hypovolemic shock cause
massive shift of fluids out of the blood vessels
result of increased capillary permeabilty
can begin as early as 20 minutes postburn
emergent phase – patho – F&E shifts – result of capillary permeability
water, sodium & later plasma proteins (especially albumin) move into interstitial spaces & other surrounding tissue
colloidal osmotic pressure decreases with progressive loss of protein from vascular space
emergent phase – patho – F&E shifts – results of capillary permeability – continued
results in more fluid shifting out of the vascular space into the interstitial spaces
fluid accumulation in interstitium termed
second spacing
other places fluid flows
also moves to areas that normally have minimal to no fluid
termed third spacing
examples of third spacing with burns
exudate and blister formation
edema in nonburned areas
other sources of fluid loss during this period –
insensible losses by evaporation
from large, denuded body surfaces & respiratory system
normal insensisble loss
30-50 mL/hr
increases in severely burned patient
net result of fluid shifts & losses is
intravascular volume depletion
other manifestations of hypovolemic shock
decreased blood pressure
increased heart rate
if hypovolemic shock not corrected
irreversible shock and death
circulatory status – result
impaired
due to hemolysis of RBCs
RBCs hemolyzed by
circulating factors (e.g. oxygen free radicals)
released at time of burn
as well as by direct insult of the burn injury
thrombosis in capillaries of burned tissue causes additional loss of circulating RBCs
resulting from fluid loss – RBCs
elevated hematrocrit
caused by hemoconcentration
after fluid balance restored – H&H
lowered secondary to dilution
Electrolyte shifts
Potassium and sodium
Sodium shifts where
to intersitial spaces
remains there until edema formation ceases
potassium shift – why
initially because injured cells & hemolyzed RBCs release potassium into the circulation
end of emergent phase – capillary membrane
restored if fluid replacement adequate
fluid loss & edema formation cease
interstitial fluid gradually returns to vascular space
diuresis
noted with low urine specific gravities
inflammation & healing – patho – burn injury causes
coagulation necrosis
tissues & vessels are damaged or destroyed
inflammation & healing – patho – result of tissue & vessel damage/destruction
neutrophils & moncytes accumulate at site of injury
fibroblasts & newly formed collagen fibrils appear & begin wound repair
wound repair within 6-12 hours after injury
inflammation & healing – patho – immunologic changes
widespread impairment of immune system
skin barrier to invading organisms destroyed
bone marrow depression occurs
circulating levels of immunoglobins decreased
inflammation & healing – patho – where do deficits occur
WBCs
inflammation & healing – patho – inflammatory cytokine cascade triggered by tissue damage
impairs the function of lymphocytes, monocytes, and neutrophils
greater risk for infections

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