3. Functions of Skin
Skin is the largest organ of the body
Essential for:
- Thermoregulation
- Prevention of fluid loss by evaporation
- Barrier against infection
- Protection against environment
provided by sensory information
4. Burn and Scalds
Burn
A burn is a type of injury
results from direct contact or
exposure to thermal , electrical,
chemical or radiation source are
termed Burns.
Scalds
Injuries results from moist heat
are termed as scalds
6. Thermal burns – Flame , hot liquid, semi
liquids , residential fires , explosion
Chemical burns- Acid, alkali or organic
compounds
7. Radiation burns – Radiation therapy , radioactive
substances and x-ray, Sun burn ( solar radiation),
Electrical burns
Inhalational injury – Asphyxiants ( Residential
Fire)
8. PATHOPHYSIOLOGY- Skin
Direct injury to skin devitalises the cells
( 40 O-44OC)
Cellular system Infarction
Sodium Potassium pump fails
Cellular edema
9. 3 Zones of tissue injury
Zone of Coagulation – Directly damaged
skin is coagulated and fully destroyed (
Inner)
Zone of stasis- Surrounding tissue exposed
to heat is edematous and has impaired
blood flow ( Middle zone)
Zone of Hyperemia- It consists of the tissue
that is inflammed and vasodilated ( Outer)
10. Pathophysiology - Fluid shifts
Following burn injury
Release of vasoactive substances ( histamine, kinins
catacholamines ,serotonin , leukotrins, prostaglandins)
Alters cell permeability( Na enters the cell and K exits the
cell)
Increases intercellualr and interstitial fluid further deplets
intra vascular fluid volume
Hypovolemia
11. Hypovolemia
Vital organs gets lack of blood supply
Decreased Blood supply to mesentric bed →
Intestitial ileus → Curling’s ulcer
Decreased renal blood → Oliguria
flow (Renal failure)
Toxins released from the wound along with sepsis
causes acute tubular necrosis.
Myoglobin released from muscles (in case of electric
injury or often from Eschar) is most injurious to
kidneys.
12. Pulmonary system
Inhalational injury by exposure to asphyxiants
Oxygen molecule are displaced and combined
of Hb to form carboxy haemoglobin ( CO
have 200 times more affinity towards Hb than
O2)
Injury to URT Leads to Erythema, ulceration ,
edema etc
Altered pulmonary resistance causing
pulmonary edema
14. Impaired skin integrity
Disruption of skin nerve endings , sweat glands
and hair follicles
Barrier function of skin is last
Immuno supression
Decreased Lymphocyte activity , Decrease in
immunoglobulin production ,suppression of
complement activity and an alteration of neutrophil
and macrophages function
Increase risk of infection
15. Metabolic
Hyper metabolic rate (BMR).
Negative nitrogen balance.
Electrolyte imbalance.
Deficiencies of vitamins and essential
elements.
Metabolic acidosis due to hypoxia and
lactic
16.
17. Psychological response
Can vary from fear to psychosis
In addition separation from family
during admission in hospital
21. Classification According to Depth
First-degree partial thickness Burns (mild): ( Superficial )
epidermis is involved . Eg . Sun burn
Pain, erythema & slight swelling, no blisters
Tissue damage usually minimal, no scarring
Pain resolves in 48-72 hours
Second degree partial thickness Burns: It appears wet .
It involves entire epidermis & variable dermis
Vesicles and blisters characteristic
Extremely painful due to exposed nerve endings
Heal in 7-14 days if without infection
22. 3rd degrees Partial thickness burns
Damage through out the dermis
Dry and may be brown , black or ivory
Denaturated skin is called Eschar
Burn tissue is not painful as a result of damage to the
nerve endings
4th degree full thickness burns
Involves skin , fat muscles and sometimes bone also
Appears tarred or may be completely burned away
Amputation is common with this injury
23. Clinical manifestations and
Assessment
Blisters over the skin
Oliguria ( < 0.5 ml/kg/1hour).
Decreased GI motility
Absence of bowel sounds , stool,
flatus
Nausea
Vomiting
Abdominal distension )
28. Emergency care phase
Time between the initial injury and 36-48
hours after injury
Fluid resuscitation
Airway , Breathing is a major concern
Assessment is important
Burn severity
Burn depth
Burn Size
Burn Location
29. Burn severity (American Burn
Association
Major burn injury – 20-25% TBSA or
burns involves the face , eyes ,ears
,hands , feet and perineum resulting
functional cosmetic disability
Moderate Burn injury – 15-20 %TBSA
Minor Burn injury – 10-15% TBSA
30. Burn depth
Superficial burns – No much
complication
Deep Burn- Produces severe injury. It
causes systemic effects , contractures
etc
Size of the Burn – Determined by
Rule of Nine
31.
32. Burn location
Burns to head and chest- Pulmonary
complication, facial burns, corneal abrasion
circumferential burns ( chest)
Burns in Ears – Auricular chondritis or
infection
Burns of hands and joints – Vocational
disability , circumferential burns
Burns to perineum – Infection
34. 1.Maintain and protect airway
Assess the oropharynx for any clinical
manifestations
Administer 100% oxygen if inhalational
injury ( Tight fitting mask continuous until
CarboxicHb level is reduced to 15%)
35. 2.Restore Haemodynamic
stability
Start IV line ( Subclavian, Internal and
external Jugular or femoral vein)
Fluid resuscitation – To restore the
functions of vital organs
36. First 24 hours Second 24 hours
FORMUL
A
Electrolyte Colloid Dextros
e
Electrolyte Colloid Dextrose
Evans NS
1 ml/kg/% of
burn
1
ml/kg/%
of burn
2000ml ½ of the Ist
24 hours
½ of the
Ist 24
hours
2000ml
Brooke RL 1.5ml/kg/%
of burn
.5ml/kg/
% of
burn
2000ml ½ - ¾ of
the
Ist 24
hour
½ - ¾ of
the Ist 24
hours
2000ml
Modified
brooke
RL 2 ml/kg/%
of burn
None None None 0.3-
.0.5ml/kg/
% of burn
Titrate to
maintain
urine
output
Parkland RL 4ml/kg/% of
burn
None None None 0.3-
.0.5ml/kg/
% of burn
Hypertoni
c saline
Fluid
containing
250meq of Na
to maintain
None None
37. 3.Minimising pain
IV narcotics
NSAID
TT
Clean the wound , Follow aseptic
techniques
Cover the wound with with sterile towel
4. Wound care
38. Acute phase ( 48-72 hours)
1. Prevention of infection
Auto contamination should be avoided
Follow aseptic techniques
PPE
Antibiotics
39. 2.Metabolic support
Aggressive nutritional Support ( energy,
healing ,prevention of harmful effects of
catabolism )
Oral intake , enteral tube feeding,
peripheral parenteral nutrition (TPN)
40. 3.Minimizes the pain
Narcotics
NSAID
Inhalational analgesics
Patient controlled analgesics
Other modalities – Hypnosis, Play
therapy, Bio feed back, Music therapy
etc
41. 4.Wound care
Daily wound care involves cleansing ,
debridement , ESCHAR -removal of
dead tissue and dressing of the wound
1% of silver sulphadioxide , Mafenide
acetate are used.
Grafting (Allograft, Autograft,Xenograft )
43. Management -Rehabilitation
Minimizes functional loss
Early wound excision
Exercise – Ambulation , active exercises
Splinting and positioning ( all three
phases)-
Static and dynamic splinting
Control of scar
Hypertrophic scarring results from
deposition of collagen
Use Custom fit anti burn support
44. Complications
Shock
Pulmonary complications due to
inhalational injury
ARF
Infection and sepsis
Curling’s ulcer
Extensive scarring and disability
Psychological trauma
Cancer ( Marjolins ulcer – 21 years )
45. Nurses role/ Goals in Burns
rehabilitation
Promoting activity tolerance
Improving body image and self concept
Monitoring and managing potential
complications
Prevent contractures of the shoulders and hips
and also to maintain their ranges.
Educate care givers on passive stretches.
Improve functional activities such as walking,
sit to stand, rolling in bed etc.
46. Purposes of medico legal
cases- Burns
To ensure that the burn patient understand the
nature of treatment including the potential
complications
To indicate that the burns patients decision
was made without pressure.
To protect the burn patient against
unauthorised procedures
To protect the hospital staff / hospital informed
consent to be taken ..
47. Circumstances requiring a permit –
Get consent to do all procedures
including admission
Consent issues – Burn patient or the
responsible adult relative of the patient
signs the consent form of the hospital