8 Determination of Burn Severity Extent Depth Age of the patient Past medical history Part of the body burned
9 Out Patient Care Burns < 20% TBSA not involving the face or hands Children over 5 years oldAdults based on assessment of their agesignificant medical historyAssess the patient and or family’s ability to care for the wound at home OR their ability to come for dressing changes.
10 Out Patient Care Goal: Close the wound as soon as possible—within 3 weeksDecrease scar and contracture formationMaintain function of involved joints
11 DETERMINATION OF SIZE OF BURN RULE OF NINESHead: %Anterior: 18%Posterior: 18%Arms: % eachLegs: % eachPerineum: 1%___Total %
12 Calculation of Percent with age consideration Berkow Method
13 DEPTH OF BURN Superficial Partial Thickness (1st degree) Skin is red only epidermis perhaps part of the dermis is injuredUsual causes: sunburn, hot liquidShould heal spontaneously within 3 weeksDeep Partial Thickness (2nd degree)Skin is red, “weepy” some blister formationUsual causes, hot thick liquids (porridge vs water)
14 Depth of Burn Con’t Full Thickness (3rd and 4th degree) Skin appears “leathery” dry, brown, hardened all epidermis and dermis is destroyed may havedestruction of sub-dermal layers, subcutaneoustissue and muscle as well.Wound will not heal, needs skin grafting oftenresults in significant scarring even with excellentwound care.
15 Partial thickness—clues moist, blister formation, Size Partial thickness—clues moist, blister formation, Size? 2year old 15% Major burn in his age group
18 Past Medical History and History of the Burn Does the PatientHave a serious medical condition?Have symptoms of an unknown disease?Take medications?Have allergies to food or medication?How did the burn occur?Source? Hot liquid, Flame? Caustic substance?Inside or Outside?Was there smoke? Was it inhaled?
19 Phases of Burn CareEmergent Phase: The time required to resolve immediate problems resulting from the burn injury Acute Phase: From the end of the Emergent Phase until the wound is closed Rehabilitation Phase: The entire program of burn care is focused to this phase. From day one of the injury until the patient returns to a useful place in society
20 Emergent PhaseFirst Aid 1. Maintain airway 2. Assess for concurrent injuries (bleeding does not occur secondary to burn injuries If there is external bleeding look for other causes). NB: Burn patients are always alert and oriented, if not assess for head injury
21 Potential for airway obstruction Burns to face and neck especially if in an enclosed space Edema formation—increased capillary permeability
22 Fluid TherapyLarge volumes of fluid escape from the burn surface causing hypovolemia in any burn greater than 20% TBSAIV Therapy: An electrolyte balanced solutionRingers Lactate (Hartman’s solution) in quantities enough to maintain adequate BP and urine output 30ml/hr in adults and 0.5ml/kg in children
23 Oral Fluid Replacement Therapy? Effective resuscitation of small (5-10%)moderate and sometimes severe burn injury.Where IV fluids may not be available or in situations with mass casualties with inadequate IV fluids.Drinking or gastric infusion of buffered saline solution.Similar to WHO oral rehydration solution1 liter of water + 8 tsps. sugar + ½ tsp salt +½ tsp of sodium bicarbonate (baking soda)Kramer, G.C., Michel, M.W. , et al (2003) Journal of Burns and Wound Care
24 Wound Care Goal: Close the wound as soon as possible Prevent infection both in the wound and systemicallyComplete grafting if necessaryDecrease incidence of scarring and contracture.
25 Wound Care Topical Agents: Other topical antimicrobials: Silver sulfadiazineOther topical antimicrobials:Mafanide Acetate (TM: Furacin)Saline, Hydrogen Peroxide & Sterile waterBetadine/ IodineHoney and Ghee
26 General Considerations: Emergent Phase Pain managementNutrition therapyPositioning /Splints
27 ACUTE PHASEAvoid, Detectand TreatComplicationsWound Care
37 Myths and Cultural Care Practices Rabbit fur (Rwanda)Powdered—un-reconstituted antibiotics (Uganda)SugarHoney and Ghee (purified animal fat)Worldview
38 ResourcesArtz, C.P.,Moncrief, J.A., Pruitt, B.A. (1979) Burns a team approach. Philadelphia, PA: W.B. Saunders. Feller, I., Archambeault-Jones, C. (1978) Teaching basic care. Ann Arbor, MI: National Institute of Burn Medicine Iwuagwu, F. C., Bailie, F. (1998) Oral fluid therapy in paediatric burns (5-10%): an appraisal. Burns 24 pp Jarlsberg, C.R. (1992) Management of Patients with Burn Injury in Brunner and Suddarth’s Textbook of Medical Surgical Nursing 7th ed. Eds. Smeltzer, S.C., Bare, B. G. Philadelphia: Lippincott Jarlsberg, C.R. ( ) Unpublished original material
39 Resources Con’tKramer, G. C. et al. (2010) Oral and enteral resuscitation of burn shock.The historical record and implications for mass casualty care. Republished fromJournal of Burns and Wound Care (2003) 2 (19) (no longer available).(no longer available) Open Access Journal of Plastic Surgery.With thanks to Rein Zeeman and Ineka Storm International Plastic Surgery SocietyHolland for sharing photographs.And thanks to the patients at Mulago Hospital Kampala Uganda for theircourage evidenced daily in facing the difficulty of recovering from burn injuries.