History and Assessment & Anatomy and Physiology of Burns

Health History and Review of System Assessment

Mr. MJ , 56 years old explosion accident.

is brought to the Emergency Room after gas tank

Vital signs

Initial assessment revealed heart rate is 142 bpm, RR- 36 breaths/min and labored. BP- 98/60, Temp-36.8 C. He states that his pain 10/10. Weight – 176 pounds

Neurology

He is alert and oriented and experiencing severe pain associated with burn injuries. He appears very anxious.

Eyes and Ears

The eyebrows, eyelashes and hair are singed. There is soot in the nares and mouth.

Respiratory

Lung sounds indicate inspiratory and expiratory wheezing and a persistent cough reveals sooty sputum production. The physician inserted a large bore central line into Mr MJ’s sublavian vein and started a rapd infusion of lactated Ringer’s solution. Mr MJ is receiving 40% humidified O2 via face mask. Initial ABG are as follows: ph – 7.49, pCO2 – 32 mmHg, HCo3 – 22 meq/L . PO2- 60 mmHG. A nasogastric tube is inserted and MJ was placed on NPO till further order.

Gastrourinary

A Foley catheter is inserted and initially drains a moderate amount of dark, concentrated urine.

Integumentray

There is thick, white leathery eschar

on the chest, neck, whole part of his back and circumferential burns on his right arm. The skin of the face is pink, moist and blistered.

MJ was started on fluid resuscitation using the Parkland formula as a guide. 

For a 80kg patient with a 45% TBSA burn: 4Ml x 80KG x 45 TBSA burn = 14, 400 mL in 24 hr - ½ of total in first 8 hr = 7, 200 mL ( 900mL/hr) - ¼ of total in second 8hr = 3, 600 mL ( 450mL/hr) - ¼ of total in third 8 hr = 3,600 mL (450mL/hr)

The lab studies sent were CBC, ABG, urinalysis, BUN, Na, K det., total protein and revealed the following findngs: H.gb -20g/dl; Hct – 52%; glucose – 168 mg/dl; BUN – 27mg/dl. Urinalysis – 20-30 pus cells/hpf Day 2 lab test revealed Lab values – Na -126 meq/L, K – 6.0 meq /L,. ABG revealed – pH -7.30, pCO2- 35 mmHG, HCO3 -18 meq/L. , Decreasing urine output. The decision to initiate dialysis was reached after thoughtful discussion with the family members. Double lumen cuffed hemodialysis IJ catheter was used in acute hemodialysis Anatomy and Physiology of Burns There are three major components of the skin. First is the hypodermis, which is subcutaneous (just beneath the skin) fat that functions as insulation and padding for the body. Next is the dermis, which provides structure and support. Last is the epidermis, which functions as a protective shield for the body. 

Hypodermis The hypodermis is the deepest section of the skin. The hypodermis refers to the fat tissue below the dermis that insulates the body from cold temperatures and provides shock absorption. Fat cells of the hypodermis also store nutrients and energy. The hypodermis is the thickest in the buttocks, palms of the hands, and soles of the feet. As we age, the hypodermis begins to atrophy, contributing to the thinning of aging skin.

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Dermis The dermis is located between the hypodermis and the epidermis. It is a fibrous network of tissue that provides structure and resilience to the skin. While dermal thickness varies, it is on average about 2 mm thick. The major components of the dermis work together as a network. This mesh-like network is composed of structural proteins (collagen and elastin), blood and lymph vessels, and specialized cells called mast cells and fibroblasts. These are surrounded by a gel-like substance called the ground substance, composed mostly of glycosaminoglycans. The ground substance plays a critical role in the hydration and moisture levels within the skin. Epidermis The epidermis is the outermost layer of the skin. Categorized into five horizontal layers, the epidermis actually consists of anywhere between 50 cell layers (in thin areas) to 100 cell layers (in thick areas). The average epidermal thickness is 0.1 millimeters, which is about the thickness of one sheet of paper. The epidermis acts as a protective shield for the body and totally renews itself approximately every 28 days. The first layer of the epidermis is the stratum basale. This is the deepest layer of the epidermis and sits directly on top of the dermis. It is a single layer of cube-shaped cells. New epidermal skin cells, called keratinocytes, are formed in this layer through cell division to replace those shed continuously from the upper layers of the epidermis. This regenerative process is called skin cell renewal. As we age, the rate of cell renewal decreases. Melanocytes, found in the stratum basale, are responsible for the production of skin pigment, or melanin. Melanocytes transfer the melanin to nearby keratinocytes that will eventually migrate to the surface of the skin. Melanin is photoprotective: it helps protect the skin against ultraviolet radiation (sun exposure). The second layer of the epidermis is the stratum spinosum, or the prickle-cell layer. The stratum spinosum is composed of 8-10 layers of polygonal (many sided) keratinocytes. In this layer, keratinocytes are beginning to become somewhat flattened. The third layer is called the stratum granulosum, or the granular layer. It is composed of 3-5 layers of flattened keratin—a tough, fibrous protein that gives skin its protective properties. Cells in this layer are too far from the dermis to receive nutrients through diffusion, so they begin to die.

The the is or

only and the 3-5

fourth layer in epidermis called the stratum lucidum, the clear layer. This layer is present in the fingertips, palms, soles of feet. It is layers of extremely

flattened cells. The fifth layer, or horny layer, is called the stratum corneum. This is the top, outermost layer of the epidermis and is 25-30 layers of flattened, dead keratinocytes. This layer is the real protective layer of the skin. Keratinocytes in the stratum corneum are continuously shed by friction and replaced by the cells formed in the deeper sections of the epidermis. In between the keratinocytes in the stratum corneum are epidermal lipids (ceramides, fatty acids, and lipids) that act as a cement (or mortar) between the skin cells (bricks). This combination of keratinocytes with interspersed epidermal lipids (brick and mortar) forms a waterproof moisture barrier that minimizes transepidermal water loss (TEWL) to keep moisture in the skin. This moisture barrier protects against invading microorganisms, chemical irritants, and allergens. If the integrity of the moisture barrier is compromised, the skin will become vulnerable to dryness, itching, redness, stinging, and other skin care concerns.

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1st Degree Burns

Damage has only been done to the first layer of skin (epidermis). The skin will turn red, become inflamed and sore. These burns require minimal treatment such as a damp/cool cloth over the affected area. 

2nd Degree Burns

Damage has gone through to the second layer of skin (dermis). The skin will turn pink/red, it may ooze liquid and blister. The affected area will swell and can have intense pain. The area will have a blotchy discoloration when pressure is applied. In extreme cases, hospitalization may be required. Otherwise, it is suggested that a damp/cool cloth is used to cool the affected area. Never use ice on a burn. 

3rd Degree Burns

Damage has been done to all three layers of skin (to the subcutaneous tissue). Skin of the affected area may be visually changed- physical depression, charring, a leathery appearance, and skin of the affected area may fall off. Internally, bones and muscles could be damaged as well. Third degree burns usually result in irreversible nerve or tissue damage. To heal the burns, skin grafts are sometimes necessary. Hospitalization is needed.

Assessment of the Adequacy of Fluid Resuscitation The extent of the burn wound is assessed using a Lund-Browder and Rule of Nines chart. This allows the accurate estimation of fluid resuscitation requirements. The type of fluid replacement is determined by size and depth of burn, age of the patient, and individual considerations, such as preexisting chronic illness. Each burn facility has a preference for a

replacement regimen. Fluid replacement is accomplished with crystalloid solutions (usually lactated Ringer’s), colloids (albumin), or a combination of the two. Paramedics generally give IVV saline until the patient’s arrival at the hospital.

The Parkland (Baxter) formula for fluid replacement is the most common formula used followed by the modified Brooke formula. Formula Parkland (Baxter)

First 24 Hours Crystalloids Lactated Ringer’s: 4.0 mL/kg/% TBSA burn; ½ given

Second 24 Hours Colloids Glucose in Water 0.3-0.5 Ml/kg/% Amount to TBSA burn replace estimated evaporative losses

Brooke (Modified)

during first 8hr; ¼ given each next 8 hr Lactated 0.3-0.5 Ml/kg/% Ringer’s: 2 TBSA burn mL/kg/% TBSA burn; ½ given during first 8hr; ½ given each next 16 hr

Amount to replace estimated evaporative losses

It is important to remember that all formulas are estimates and must be titrated based on the patient’s physiologic response. For example, patients with an electrical injury may have greater that normal fluid requirements. Colloidal solutions (e.g albumin) may be given. However, administration is recommended after the first 12 to 24 hours postburn when capillary permeability returns to normal or near normal. After this time, the plasma remains in the vascular space and expands the circulating volume. The replacement volume is calculated based on the patient’s bodyweight and TBSA burned. (e.g., 0.3 to 0.5 mL/kg/% TBSA burn) Assessment of the adequacy of fluid resuscitation is best made using clinical parameters. Urine output, the most commonly used parameter, and cardiac parameters are defined as follows: 1. Urine output: 0.5 to 1 mL/kg/hr; 75 to 100 mL/hr/for electrical burn patient with evidence of hemoglobinuria/myoglobinuria. 2. Cardiac factors: Mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats per minute. MAP and BP are most appropriately measured by an arterial line. Peripheral measurement is often invalid because of vasoconstriction and edema.

The Stages of Burns 1. Shock Phase or Fluid Accumulation Phase or Emergent Phase

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It occurs during the first 48 hours post-burns. Fluid shifts from intravascular compartment to interstitial compartment (IVC to ISC). This leads to generalized dehydration. - Hypovolemia occurs due to plasma loss. This causes decreased cardiac output and fall of BP. - Hemoconcentration, increased hematocrit. Plasma is lost into the interstitial compartment (ISC). - Oliguria. This is due to decreased renal tissue perfusion, decreased release of ADH and Aldosterone. These are body’s responses to hypovolemia. - Hyperkalemia and hyponatremia. This results from release of potassium from damaged cells; sodium is trapped in the edema fluids (ICS). - Metabolic acidosis. This results from accumulation of metabolites, hyponatremia and hyperkalemia. Primarily, it is due to hyponatremia. Since sodium is unavailable because it it trapped in the edema fluids, bicarbonate produced by the kidneys will be excreted. 2. Diuretic or Fluid Remobilization phase - This occurs after 48 hours post burns. Fluid shifts from interstitial compartment to intravascular compartment (ISC to IVC). - Hypervolemia, hemodilution and decreased hematocrit occur. This is due to fluid shift from ISC to IVC. - Diuresis. This is due to increased renal tissue perfusion, decreased ADH and Aldosterone secretion. - Hypokalemia, hyponatremia. Potassium moves back into the cells; sodium is still trapped in the edema fluids. - Metabolic acidosis. Decreased sodium levels cause of excretion of bicarbonate by the kidneys. 3. Recovery Stage - This occurs on the 5th day, onwards. - Hypocalcemia. This results from loss of calcium in the exudates. It is also due to utilization of calcium in the granulation tissue (scar) formation in the areas of burns. - Negative nitrogen balance. In stress like burns, there is increased protein catabolism. Protein demands are increased for healing and protein intake may be inadequate. - Hypokalemia. Potassium has shifted back into the cells, serum levels are decreased.

Management

The first aid intervention for burns are as follows: 

Stop the burning process 1. Immerse the affected part in the cold water 2. Drop and roll. Advise the client to drop and roll on the ground if clothing is in flame. 3. Throw a blanket over the client to extinguish the flame. This cuts off source of oxygen from the environment and the flame will spontaneously be extinguished.

Collaborative Management for clients with burns include the following: 1. Promote respiratory function  Assess for sooty sputum and singed hair in the nose and eye brows (Singed hair is stiff and rigid burnt hair)  Establish an open airway  Administer oxygen therapy 2. Promote fluid-electrolyte and acid-base balance  Assess the following parameters: - Vital signs - Urine output - Central Venous Pressure (CVP) - Level of Consciousness - Weight - Percentage of Burns  The vital changes in dehydration are as follows: - Weight loss - Decrease urine output - Decreased CVP - Decreased level of consciousness - Changes in vital signs: elevated body temperature, increased pulse rate, rapid respiratory rate, low blood pressure.  The rule of 9’s for determining percentage of burns in an adult 3. Relieve Pain  Administer Morphine Sulfate IV as prescribed. Monitor the client for respiratory depression. Have Narcan (Naloxone) readily available.  Use bed cradle to relieve pressure from the top sheet and to prevent sticking of exudates to the top sheet.  Avoid exposure of affected areas to draft. Sudden gush of wind causes hypersensitivity of exposed nerve endings. 4. Prevent infection  Practice asepsis. Handwashing is the most important to prevent spread of microorganism.

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Implement reverse or protective isolation Administer tetanus immunization Irrigate affected area with normal saline (NS) solution Maintain adequate nutrition Do not give oral fluids for the first 24 hours. To prevent paralytic ileus, gastric dilation, and water intoxication.  Provide high calorie, high carbohydrates, high protein diet.  Provide diet rich in Vitamins A, B, and C. Vitamin A maintains skin and mucous membrane integrity. Vitamin B enhances metabolism. Vitamin C increases resistnace to stress and infection. 6. Provide wound care