Professional Documents
Culture Documents
Complied by:
Peter Igneri, PA-C, Jennifer Gratton, RN
Table of Contents
INTRODUCTION ................................................................................ 4
INITIAL ASSESMENT........................................................................ 5
INHALATION INJURY ....................................................................... 8
ESTIMATING TOTAL BODY SURFACE AREA OF BURNS.......... 12
TYPES OF BURNS AND TREATMENTS........................................ 15
DRESSING CHANGES.................................................................... 22
DRESSING TYPES FOR BURNS.................................................... 25
TOPICALS FOR BURN DRESSINGS ............................................. 29
EXCISION AND BURN GRAFTING ................................................ 31
MANAGEMENT OF SPECIFIC BURN AREAS ............................... 35
CHEST...................................................................................................................... 35
AXILLA.................................................................................................................... 35
NECK AND BREAST.............................................................................................. 36
LOWER EXTREMITIES ......................................................................................... 36
UPPER EXTREMITIES........................................................................................... 37
HANDS..................................................................................................................... 37
BACK ....................................................................................................................... 38
PHASES OF GRAFT MATURATION........................................................................ 39
LONG TERM COMPLICATIONS.............................................................................. 41
BURN NUTRITION........................................................................... 44
BURN NUTRITION - PEDIATRIC .................................................... 50
BURN REHABILITATION................................................................ 53
INTRODUCTION
This burn care document was developed by the burn committee as a
resource for Fletcher Allen staff that may have questions in regards to
caring for the burn patient.
Although there are advances in burn treatments most of the
documents in this binder remain the standard of care for the patient.
As new treatment develops the manual can easily be updated.
Thanks to all of the people that researched information for the manual
for all there time and effort.
Fletcher Allen Burn Committee
Jennifer Gratton, RN Trauma Program Supervisor
Peter Igneri, PA Trauma Service
Lori Camp, RN Trauma Case Manager
Jess Langer, RN Care Coordinator Baird 6
Pam Kupiec, RN Baird 6
Marie Zebertavage, RN Baird 6
Tracey Wagner, RN Baird 5
Carole Richards, RN Baird 5
Gail Tuscany, RN SICU
Patrick Delaney, RN SICU
Patty Crease, RN SICU
Gil Helmken, RN ED
Ray Scollins, RN FACT
Kristen Brewster Occupational Therapy
Barb Blokland Occupational Therapy
Karyann Bombardier Physical Therapy
Julie Jacob, SW Trauma Social Worker
Burn Care
INITIAL ASSESSMENT
Primary Survey
A Airway.
Secure the airway first.
Get history as much as reasonably possible before intubation
Soot or singed nasal hairs?
B Breathing;
High flow Oxygen for all.
Escharotomy? - Monitor chest wall excursion in presence of FT torso
burns
Listen: verify breath sounds
Assess rate & depth
C Circulation
Monitor BP,
pulse rate,
skin color
Establish IV access,
Warm IV fluids
Monitor peripheral pulses in circumferential burns.
D - Disability;
Associated Injuries?
CO poisoning?
Substance abuse?
Hypoxia?
Pre-existing medical condition
E Exposure;
Remove all clothing and jewelry
Ensure warm environment
Clean DRY blankets
It is OK to use water to stop the burning process and clean but not at the
expense of reducing body core temperature.
Secondary survey
Repeat Primary
Complete head to toe evaluation
Start after resuscitation fully established
BURN CARE MANUAL FAHC
INHALATION INJURY
The three injury processes, resulting from smoke exposure, are presented in the
order in which peak symptoms occur.
Carbon Monoxide Toxicity- peak symptoms immediate
Upper Airway Injury with Potential Obstruction peak
symptoms can be delayed for an hour or more
Lower Airway Injury with Impaired Gas Exchange- peak
symptoms can be delayed for hours
Carbon Monoxide Toxicity
Pathophysiology:
Carbon Monoxide binds to the hemoglobin molecule displacing oxygen thereby
decreasing the oxygen delivered to tissue. The affinity of CO to hemoglobin is
much higher than O2.
Risk Factors
Any exposure to smoke
Any exposure to fumes
Diagnosis
Pulse oximeter may be completely normal value as it only measures O2 level.
A high index of suspicion in any fire victim with a history of smoke exposure
A carboxyhemoglobin level exceeding 10% total (Morbidity is related to
peak level at scene not the first value obtained)
Unexplained metabolic acidosis
Hgb Level
Carbon Monoxide
Intoxication
CO High Symptoms
0-5
Normal Value
15-20
Headache, Confusion
20-40
Disorientation, fatigue,
nausea, visual changes
40-60
Hallucination,
combativeness, coma,
shock, shock state
60 or
above
Cardiopulmonary arrest,
Death
Cyanide
Obtunded
Metabolic Acidosis
Intubate
Cardiovascular support
Hyperbaria used if
patient not
responding to 100%
oxygen (specific
indications remain
undefined)
Upper Airway Injury:
Pathophysiology:
Direct heat injury caused by the inhalation of air heated to a temperature (150 C
or higher) ordinarily results in burns to the face, oropharynx, and upper airway
(above the vocal cords). Even superheated air is rapidly cooled before reaching
the lower respiratory tract because of the tremendous heat-exchanging efficiency
of the oropharynx and nasopharynx.
10
Inhalation Burns
30
11
12
It takes into account the age of the patient as it relates to the TBSA.
SAGE diagram
Another tool to use is the Sage Diagram. This is available via the internet at:
www.sagediagram.com
This is a free service which permits the user to draw in the areas burned on a
diagram, and based on the patients height and weight will provide an estimated
total body surface area of burns. This diagram can be printed for charting.
13
Estimating the size of the Burn as a % of the Total Body Surface (TBSA)
14
15
Appearance
The micro vessels perfusing this area are injured resulting in the
leakage of large amounts of plasma, which in turn lifts off the heatdestroyed epidermis, causing blisters to form. The blisters often increase
in size even after the burn. A light pink, wet appearing very painful wound
is seen as the blisters are disrupted. ** Frequently, the epidermis does not
lift off the dermis for 12 to 24 hours and what initially appears to be first
degree is actually a second degree burn.
Treatment
Debridement of affected skin to expose underlying wound. Debride
blisters that are limiting joint movement.
Clean wound and apply antimicrobial ointment such as bacitracin.
Excellent alternative is the use of skin substitute which seals the wound
and decrease pain. Below is an example of Biobrane application-usually
put on in the Emergency Department setting.
16
Also can apply closed dressing of gauze for absorbency and wrap.
This will need to be changed daily.
Healing
This type of burn heals in 10-12 days without scarring. There is a low
risk of infection.
17
Appearance
The burn surface may have blisters but is redder and less wet.
Treatment
Treatment is typically Silvadene cream and occlusive dressing with a
closed dressing technique. A temporary skin substitute is also a treatment
of choice.
Healing
This type of burn usually heals in 2 to 4 weeks. The longer the
healing time, the more chance of scarring.
Deep Second Degree-Deep partial thickness
In this type of burn most of the skin is destroyed except a small amount of
remaining dermis. The wound looks white or charred indicating dead
tissue. Blood flow is compromised and a layer of dead dermis or eschar
adheres to the wound surface. Pain is much less as the nerves are actually
destroyed by the heat. Usually, it is difficult to distinguish a deep dermal
burn from a full thickness burn by visualization. The presence of sensation
to touch usually indicates the burn is a deep partial injury.
18
Appearance
The wound surface may be dry and red in appearance with white
areas in the deeper parts. There is marked decrease in blood flow making
the wound very prone to conversion to a deeper injury and to infection.
Direct contact with flames is a common cause. The appearance of the deep
dermal burn changes dramatically over the next several days after burn as
the area of dermal necrosis along with surface coagulated protein turns the
wound a white to yellow color. This resembles the third degree burn and
differentiation sometimes is difficult. The presence of some pain can assist
in diagnosis because the pain is usually absent in full thickness injury.
Treatment
Wash with antimicrobial soap and water. Apply silvadene closed
dressing. Often grafting is needed to speed healing. Monitor for infection.
Often converts to full thickness injury.
19
20
Treatment
Wash with antimicrobial soap and water. Apply Silvadene cream with a
closed dressing. Grafting is treatment of choice. High risk for infection.
21
DRESSING CHANGES
FULL THICKNESS AND DEEP PARTIAL THICKNESS (PRE-GRAFT)
Procedure:
1) Wash and/or have patient help wash all affected areas with anti-bacterial soap and
water
22
DRESSING CHANGES
PARTIAL THICKNESS AND DONOR SITES
23
24
25
26
27
White cotton Gloves these are simply white cotton gloves used as a dressing.
It allows for increased mobility while still protecting the burn. Hands and glove
are coated in appropriate topical agent (usually bacitracin). These gloves can be
cleaned and dried and used again. Turn gloves inside out so seems are on the
outside (more comfortable).
BandNet (Spandage)
Tubular mesh netting type dressing that allows contact
layers to stay in proximity to the wound. Sometimes used
on the OR in order to apply pressure to the dressing and
keep graft in place. When used over a graft will be stapled
in place.
28
29
Fungal colonization in and below eschar may occur concomitantly with reduction
of bacterial growth in the burn wound. However, fungal dissemination through the
infected burn wound is rare.
SILVER NITRATE: Used in liquid form as a wet dressing over partial and full
thickness burns, for patients with sulfa allergies. Requires frequent re-application
to keep area moist.
Action: Silver Nitrate is a topical solution agent with bacteriostatic properties
against staph aureus, E. Coli, and Ps. Aeruginosa. It is most effective with the
wound is clean and dbrided of all dead tissue.
Precautions: May cause hyponatremia, monitor electrolytes closely.
Will cause discoloration of skin, clothes and equipment.
BACITRACIN: Used with partial thickness burns, with grafted areas initially after
dressing removed, with donor sites until nearly healed, and with facial burns.
Action: Bacitracin is produced by a strain of the bacterial species Bacillus
subtilis. It is widely used for topical therapy such as for skin and eye infections; it
is effective against gram-positive bacteria, including strains of staphylococcus.
Precautions: May cause burning, redness or a rash at which time the ointment
should be stopped.
EUCERIN: Used for first degree (superficial) burns and for healing partial
thickness burns, grafted burns, and donor sites to keep area moist.
Action: Moisturizing lotion
30
Pedicle grafts - with a pedicle graft a portion of the skin used from the
donor site will remain attached to the donor area and the remainder is
attached to the recipient site. The blood supply remains intact at the donor
location and is not cut loose until the new blood supply has completely
developed. This procedure is more likely to be used for hands, face or
neck areas of the body.
The success of a skin graft can be determined within 72 hours of the surgery. If a
graft survives the first 72 hours without an infection or trauma the body, in most
cases, will not reject the graft. Before the surgery, the recipient and donor sites
must be free of infection and have a stable blood supply. Following the procedure
moving and stretching the recipient site must be avoided. Dressings need to be
sterile and antibiotics may be prescribed to avoid infection.
BURN CARE MANUAL FAHC
31
EXCISION
There are two types of excisions when skin grafting, fascial and tangential.
Fascial: burn eschar is excised down to muscle fascia. Good graft take,
decreased bleeding, fast. Cosmetic and functional results worse than with
tangential excision. Perform where burn depth is deep into subcutaneous
tissue, person may not tolerate blood loss, or where reduced blood loss
and stress outweigh cosmetic and functional advantages of tangential
excision
32
EXCISION
PROS
Tangential
Improved function
High blood loss
Improved cosmesis Need more skin
Takes longer
Risk over/under excision
End points hard to define
Rapid
Cosmetic defect
Defined endpoints Risk of nerve injury
Wide-mesh grafts
Risk of joint exposure
Good graft take
Distal edema
Skin substitutes
Fascial
CONS
FASCIAL EXCISION
TANGENTIAL EXCISON
Early excision and grafting (2-5 days post injury) is associated with improved
outcomes. After one week there is and increased dermal blood flow and
BURN CARE MANUAL FAHC
33
granulation is forming under eschar. This results in an increased blood loss with
excision.
It is best to only excise up to 18-25%TBSA in the first operation and never more
than 18% in a single operation after that.
Monitor the patients temperature closely and if unable to maintain normothermia
the operation should be stopped.
Post operatively patients may experience periods of hypotension and decreased
urine output. This is due to vasodilatation, re-warming and loss of the tourniquet
effect after the constricting eschar is removed.
EXCISION AND GRAFTING IMPORTANT POINTS:
-harder than you think
-requires planning ahead to figure out what you want to accomplish and how you
are going to accomplish it
-what are you going to use for back up skin (cadaver, Biobrane, Integra)
-what type of excision
-what type of graft
-what is the best position for the patient
-make sure you have enough help before you go the to OR
-If burn requires splinting, make sure to coordinate with therapists in advance
Surgical Approach Based on Burn Size-Must Prioritize
1. Life
2. Limb
3. Looks
34
AXILLA
35
LOWER EXTREMITIES
36
UPPER EXTREMITIES
HANDS
37
BACK
Immobilize seams
Cover with Xeroform, will separate from donor site when healed
Deep donor sites (>0.016 inch) should be grated with a thin (0.005 inch)
graft to speed healing and minimize scarring
38
39
40
HYPERTROPHIC SCARRING
Hypertrophic scar
more common after
spontaneous closure
of DPT burns or
healing of widely
meshed grafts.
Deep donor sites.
HYPERTROPHIC SCARRING
Compression
garments can help
control hypertrophic
scarring.
Restrict capillary
blood flow.
Garments worn 12-18
months for 23 hours a
day, 7 days a week.
41
CONTRACTURES
Grafts and
spontaneously
healing burns may
develop contractures.
Splinting, aggressive
OT/PT, and early
grafting may prevent
contractures.
HETERTROPHIC
OSSIFICATION
Bone deposition outside of bone. X-rays
show calcifications in soft tissues.
? Causes
Often occurs in joints injured by burns or in
grafted or healed burns.
May show up months-years after injury.
Symptoms pain, limitation of mobility.
Treatment PT, analgesics, surgery.
42
Marjolins Ucer
Squamous cell
carcinoma that can
occur in an area of
healed or grafted
burns.
May develop decades
after the original
injury.
43
BURN NUTRITION
Characteristics:
Nutrition needs are altered in patients with burns. Energy (calorie) and protein
needs are elevated and remain high after a burn and during subsequent
treatment. If other injuries accompany the burn, the additional injuries also
increases calorie needs. Protein losses and energy expenditure are directly
related to the size of the burn. Nutrition support for the burn patient requires
meeting energy and protein needs. Periodic re assessment of calorie needs
during recovery prevents complications from overfeeding. Providing enough
calories and protein can help minimize loss of lean body mass and enable
healing.
Calorie needs:
Energy needs surge 7 to 10 days post burn. Calorie needs may change due to
change in patient status. Injuries and infections can also increase calorie
requirements.
Best practice is to re assess calorie needs weekly, taking into consideration
changes in condition including extubation, activity, infection, surgery and
frequency of dressing change. Indirect calorimetries, or metabolic carts, provide
the most accurate evaluation of calorie needs when compared to predictive
equations.
Calorie needs will be high before grafting and decrease afterwards. Good
nutrition is needed to heal the donor sites along with the grafted burns.
The metabolic cart can measure energy expenditure (MEE) over a brief period of
time. This information can be extrapolated to twenty four hour caloric
requirements. The results of the metabolic carts can be multiplied by 1.1 to 1.3 if
the patient is active with physical therapy or dressing changes. The timing of the
metabolic cart is key in getting an accurate study. It is helpful for the patient to be
tolerating tube feedings at goal as the metabolic cart is performed.
Predictive equations are another way of assessing calorie needs. Ireton Jones
and Harris-Benedict are two of the predictive equations commonly used in
assessing calorie needs of burn patients. In intubated patients periodic metabolic
carts will give more accurate and useful information when compared to a
predictive equation in determining the calorie needs of burn patients.
44
Stress factors
1.2
1.3
1.2
1.3
1.4
1.6
1.2
1.6
1.7
1.8
1.9
1.9-2
1.5
Protein needs:
Protein needs are also elevated in patients with burns. Typically patients receive
1.5 grams of protein per kg but may require close to 2.5 grams of protein per kg
per day. Although providing high amounts of protein to burn patients will not
ameliorate catabolism, it will contribute to anabolism and enable healing. Protein
is needed to heal burn and graft sites. Patients with burns have protein loss due
to loss of skin from the burn itself.
Nutrition support:
Enteral nutrition is best practice in all patients including burns. Enteral nutrition is
better utilized, supports immune function and improves outcome. If enteral
access is safe and available, starting tube feeds early in the patients hospital
BURN CARE MANUAL FAHC
45
stay will decrease ventilator days and length of stay. Patients may also eat if
getting tube fed.
Tube feeds should be initiated in all patients with:
Burns >20% of TBSA
Burns >10% with other significant injuries
Elderly patients
Patients who will frequently be NPO for surgery/dressing
changes/procedure requiring sedation.
Patients with baseline nutrition compromise such as a history of
unintentional weight loss.
In patients lacking in safe enteral access Total Parenteral Nutrition (TPN) can be
used as a nutrition source until the patient can be fed enterally. TPN solutions
are customized to the patient individual needs. The TPN is monitored to maintain
its safely and usefulness.
Enteral nutrition:
The tube feed of choice for the burn patient on formulary at FAHC now is Crucial.
Crucial is a high protein, high calorie enteral formula. It contains hydrolyzed
casein as a protein source which has been shown to be better absorbed in
critically ill patients. The primary fat source is marine oil. The omega 3 fats in
marine oil act as immunomodulators. It does contain arginine, another nutrient
associated with wound healing. It is supplemented with elevated levels of key
nutrients associated with wound healing. It can be fed into the stomach or small
bowel. Details of the nutrient content of this product are posted on the nutrition
services web site.
http://intranet.fahc.org/Depts/Nutrition/Nutrition_Contrib/Documents/Diet_Order_
Guide.pdf
Typically when tube feedings are started they are run continuously, they can be
run over shorter periods of time to allow time off for meals or therapy. Tube
feedings can act as a sole source of nutrition or as a supplement to a regular
diet.
Crucial is contraindicated in:
46
Diet by mouth:
If the patient is able to eat, a regular, high calorie high protein diet is best choice.
In addition to the patients meals, snacks and supplements can provide addition
calories. The supplements available at FAHC are posted on the nutrition services
web site. The best choice supplement is the one the patient will take on a regular
basis. Low sugar supplements are available for patients with diabetes. Lactose
free supplements are also available. The diet tech can assist patient with meal
selection and indicate high protein options on the menu. They will also offer
snacks and supplements.
A complete list of high calorie supplements is available at:
http://intranet.fahc.org/Depts/Nutrition/Nutrition_Contrib/Documents/Diet_Order_
Guide.pdf
The dietitian will also meet with the patient and their family and discussed the
reason for high protein high calorie diet and suggest options from the menu and
supplement on the formulary. At least 3 meals and 2 snacks per day are
encouraged. Nutrition services will accommodate patients special requests as
able. Typically patients receive a supplement at every meal.
The aim of providing high calorie supplements to burn patients is to provide
addition calories and protein for healing. The supplements are intended to be
consumed in addition to meals; typically they are not a meal substitute. For
patients who cant tolerate solid food or are only drinking ensure plus, four to five
cans of ensure plus are needed per day to prove close to adequate calories.
Supplements such as ensure or mighty shakes can be consumed between meals
and in the evenings to avoid interfering with meal time appetite. This is a good
strategy for patients who have a poor appetite or feel full quickly.
Patients often fatigue if consuming the same supplement for a long time, varying
the type of supplement can help patients continue to drink supplements. The best
choice of supplement is the one the patient is willing to consume on a regular
basis. Although ensure plus is the highest in calories, some patients may prefer
mighty shakes or CIB (a fruit juice based supplement).
High protein foods include chicken, turkey, beef, fish, eggs, milk and other dairy
products, and nuts. Good snack choices are sandwiches, yogurt, cottage cheese,
milk, peanut butter or cheese and crackers, egg, tuna or chicken salad. All are
available as between meal snacks.
Other high calorie, high protein foods are available on the patient menu. The
patient will be encouraged to choose these. Also burn patients will be offered
between meal snacks. The overall goal is to allow the patient to maximize calorie
47
and protein intake for healing. FAHC nutrition services will try to accommodate
special requests.
Supplemental vitamin and nutrients:
Supplemental vitamins are required when healing burns to provide specific
nutrients for healing and to compensate for losses via the burns. Vitamin C is a
component of collagen formation. Zinc is lost when skin or gastrointestinal fluids
are removed/lost. Glutamine is a nutrient that acts as an immunomodulator.
Arginine has been shown to enable wound healing in some studies. Arginine is
contraindicated in septic patients.
In patients taking a regular diet with small burns, likely there is no benefit in
giving supplemental vitamins except a multivitamin and mineral and vitamin D.
Listed below are commonly given supplements, dose and who will most benefit.
Nutrient
Vitamin C
Zinc (ZNSO4)
Multivitamin
and mineral
Vitamin A
Tube feed
combined with
diet
500 mg per
1000 mg per
day
day
220 mg per
220 mg per
day
day for 14
days
One chewable One chewable
tablet daily
tablet daily
None
None if tube
fed > 1 liter
per day
Vitamin D
None
Arginine
supplement
Glutamine
None
400 IU per
day
None
10 grams 3
times per day
10 grams 3
times per day
Diet only,
large burn
Diet only,
small burn
1000 mg per
day
220 mg per
day for 14
days
One chewable
tablet daily
10,00 iu po
Monday,
Wednesday
and Friday
400 IU bid
None
None
One chewable
tablet daily
none
400 IU daily
Two packets
None
daily
10 grams 3
None
times a day as
tolerated
Monitor:
Monitoring the patients response to nutrition support allows for changes to best
provided nutrition for healing. Nutrition services will review the bedside flow sheet
to see the amount of TPN or tube feed the patient receives. Also, patients eating
by mouth are closely monitored using the flow sheets. Calorie counts can be
implemented in patients who are eating poorly and are candidates for
48
supplemental tube feeds. Weekly weights are needed to evaluate if the patient is
consuming enough calories.
Labs:
Prealbumin is affected by acute stress and will be low early in the hospital
course. It is not a good indicator of response to nutrition therapy early in the
hospital stay. It can be helpful when the patient is no longer acutely stressed.
Actual nutrient intake is the best way to evaluate nutrition status. Patients, who
are eating poorly, or not at all, either have a nutrition problem or will soon
develop one.
Electrolytes, magnesium and phosphorus should be followed daily in patients
receiving nutrition support.
Close monitor of blood sugars, at least initially, even in non diabetic patients is
needed.
Prepared by
Karen Tufano RD CD
Bonnie Beynnon RD CD CNSD
49
108 kcal/kg
98 kcal/kg
Children
1-3 years
4-6 years
7-10 years
102 kcal/kg
90 kcal/kg
70 kcal/kg
Male
11-14 years
15-18 years
55 kcal/kg
45 kcal/kg
Female
11-14 years
15-18 years
47 kcal/kg
40 kcal/kg
Another formula which is also for children with burns is the Curreri formula.
This formula is generally not used at this facility.
Monitoring the burned pediatric patient
A nutrition assessment protocol depending on the severity of the patients burn
and alertness would include the following:
- A diet history
50
Protein Needs:
Protein needs are elevated in burned pediatric patients, and it is recommended
that 20-23% of the calories be provided as protein with >10% BSA burns which
translates to about 2.5-4.0 grams protein/kg.
Micronutrient Needs:
Micronutrient needs increase based on the severity of the burn, and stores of
micronutrients are lower in a young child. The following are recommendations
for vitamins and mineral supplementation in the burned child: (3)
Children and adolescents (3 years and older)
1. Major burn
- one multivitamin daily
- 500 mg ascorbic acid twice daily
- 10,000 IU vitamin A daily
- 220 mg zinc sulfate daily
2. Minor burn (<20%) or reconstructive patient
- one multivitamin daily
Children (<3 years of age)
1. Major burn
- one childrens multivitamin daily
- 250 mg ascorbic acid twice daily
- 5000 IU vitamin A daily
- 100 mg zinc sulfate daily
2. Minor burn
- one multivitamin daily
Children with burns <20% of body surface area usually can meet their energy
and protein needs with a high calorie, high protein oral diet. Snacks should be
offered along with a multivitamin. High calorie shakes may be offered.
If the patient has a larger burn, energy needs may not be met by oral feeds
alone, and supplemental tube feeds may be needed. Feeding enterally is always
51
the preferred method, but if the patient is unable to tolerate enteral feeds,
parenteral nutrition may be needed.
References:
1. Young VR, Motil KJ, Burke JF. Energy and protein metabolism in relation to
requirements of the burned pediatric patient. Textbook of Pediatric
Nutrition. New
York, Raven Press; 1981: 309-340.
2. Curreri PW, Richmond D, Marvin J, et al. Dietary Requirements of patients
with major burns. J Am Diet Assoc. 1974; 65: 415-417.
3. Samour PQ, Helm KK, Lang CE, Handbook of Pediatric Nutrition (2nd
edition). Aspen Publishers, Inc. Gaithersburg, Maryland 1999: pg 502.
52
BURN REHABILITATION
Burn rehabilitation is a
24 hour a day process!!!!
The ultimate goal of burn rehabilitation is to return the patient back to society in
as near to their normal functional capacity as what existed prior to the burn injury,
through prevention and treatment of burn scar contracture deformity and
hypertrophy scarring. This goal is achieved through functional activities, exercise
programs, splinting, positioning, and scar management.
Functional Activities
Outcomes: Prevent loss of function during hospitalization or prevent
secondary complications. Reinforce carry over of ROM and strengthening
exercise programs.
Exercise Programs
Outcomes: Maximize functional ROM and strength through exercise
programs to be carried out by the patient and or caregivers.
Splinting
Outcomes: Protect joints and tendons, provide optimal positioning for
wound and graft healing, maximize and maintain ROM (see photos on following
pages).
53
54
55
56
57
58
usually on the face or extremities. The deeper tissues remain soft and pliable.
After thawing, the area becomes red and sensitive, and slight edema with a few
small blebs may appear. A few days later, the skin may peel.
Deep frostbite, a much more serious injury, usually occurs in the hands and feet.
Inspection shows a cold, waxy, pale, or cyanotic member, solid and unyielding,
which resembles a piece of chicken just out of the freezer. After thawing, blisters
of various sizes usually develop. A relatively favorable sign is the occurrence of
huge blisters filled with pinkish fluid, extending close to the tips of the affected
digits. In more severe frostbite, the blisters tend to be smaller and filled with a
darker fluid, the part remains numb and cool, and the joints remain stiff. In the
most severe cases, the frozen area is completely numb, cold, and bloodless,
without blisters or edema, and gangrene develops rapidly. The amount of
damage tends to be overestimated in the early stages, and amputation should be
delayed if possible until clear demarcation occurs.
Signs & Symptoms of Frostbite
Tingling and burns are early symptoms and a warning to get out of the cold
immediately. If this isn't possible, vigorously move the affected part to increase
circulation.
The next stage is numbness. By this time, you probably have frostbite.
In the third stage, skin may appear pale or white and cold to the touch.
In the final stages, there is a swelling and blisters may form after the skin thaws.
A physician should examine all frostbite as soon as possible. Prompt treatment
will increase the chance for complete recovery.
Initial Management
Superficial frostbite can be thawed by direct body heat, such as a warm hand on
a frozen cheek, or by general body warming indoors.
The preferred initial treatment for deep frostbite is rapid re-warming on a water
bath at a temperature of 104 - 108oF. Rapid re-warming should not be performed
in the field if there is a danger that the extremity might be frozen. The re-warming
flushing process is quite painful, and narcotics may be required for relief of pain.
Vasodilatation in the affected member is encouraged by raising the body core
temperature with direct heat to other parts of the body and hot drinks.
After thawing, the once frozen part is wrapped in clean, soft material. Toes and
fingers are separated with cotton pledgets, and the limb is elevated to minimize
swelling. Patients should not be allowed to walk on a thawed foot. Smoking is
prohibited.
Tissue loss will be less with rapid re-warming even if the part has been frozen for
several days.
59
Frostbite protocol
Admission/ED: Rewarm affected areas rapidly in warm water (40-42C) for 15
to 30 minutes or until thawing is complete.
On completion of re-warming: treat the affected parts as follows:
1. Dbride white blisters and institute topical treatment with aloe Vera every
6 hours.
2. Leave hemorrhagic blisters intact and institute topical aloe Vera every 6
hours.
3. Elevate affected parts with splinting as indicated.
4. Administer anti-tetanus prophylaxis (toxoid or Ig).
5. Provide analgesia: opiate IV/PO PRN.
6. Administer ibuprofen 4-600 mg orally Q 12 hours.
7. Administer penicillin 500 mg PO Q 6 hours for 48 to 72 hours.
8. Begin ASAP QD hydrotherapy (PT consult) for 30 to 45 min. @40C. Until
devitalized tissue sloughs. Less benefit if delayed >48 hr.
9. Documentation: obtain photographic records at
a. Admission
b. 24 hours
c. Every 2 to 3 days until discharge.
10. Smoking: Prohibit the patient from smoking/nicotine.
11. After hydrotherapy has reached maximal benefit, switch to
bacitracin/Sulfamylon/silvadene as indicated.
12. Debridement is carried out PRN in the office setting or in the OR over the
next 1-2 months.
13. Consider contacting interventional radiology or vascular for possible tPA,
reserpine, or other angiographic revascularization of cold, insensate but
not necrotic extremities (i.e. early intervention). There is some literature
showing benefit. Consult Drs. Morris, Najerian, Bhave or Sartorelli for
guidance if unsure if patient is candidate for angiographic intervention.
Adapted from Murphy JV, Banwell PE, Roberts AH, et al. Frostbite: pathogenesis
and treatment. J Trauma 2000;48(1):171-8; Gentilello LM, Rifley W. Continuous
arteriovenous rewarming: report of a new technique for treating hypothermia. J
Trauma 1991;31:1151-4; Reduction of the Incidence of Amputation in Frostbite
Injury With Thrombolytic Therapy. Bruen, K. J., MD, et al. Arch
Surg. 2007;142:546-553.
60
PEDIATRIC BURNS:
SPECIAL
CONSIDERATIONS
Age < 10 with greater than 10% TBSA burns- second and third degree
Age > 10 with 20% TBSA burns
Third degree burns > 5%
Burns to face , hands, feet, genitalia, or overlying major joint
Suspected Abuse: Mechanism of injury is consistent with developmental
status and must match clinical picture
It bears repeating:
< 10% Burns- start on maintenance with fluid bolus as needed
Pediatric Parkland formula for 2nd and 3rd degree
o 2-4 ml RL X kg X % BSA burn
o in 1st 8 hrs
o in 2nd 8 hrs
o in 3rd 8 hrs
o In children, must add dextrose containing maintenance IV fluids in
addition to resuscitation: use D5LR100cc/kg for 10 kg of weight
50 cc/kg next 10 kg of weight
20cc/kg remaining weight
Goals:
61
Support for the child and family is critical. When children are frightened and
uncomfortable, they may regress to the developmental level that allows them to
deal with the stress of the injury. They may be confused by the intensity of
concern given to their physical needs and care. All children need reassurance
that they are all right and that they will get better.
General Care Guidelines include:
Tell child first before doing anything
Allow for choices whenever possible
Give descriptions of sensations that may be felt as well as what child can
do to cope with them
Do not use words such as done or finished until burn care is completed
Avoid emotional words such as pain, scream or hurt
Utilize treatment rooms or spaces other than childs bedroom for dressing
changes and interventions -in order to maintain a safety zone
Establish ground rules before procedure. For example, agree on an
allotted time for dressing change or to identify who may perform what
piece of dressing change
If child refuses to focus on dressing change or refuses to actively
participate- continue to encourage cooperation. Reinforce with praise and
gradually increase expectations for childs participation in care
If child cannot help- encourage child to count 1-10 or 20 as fast as
possible, rest for agreed upon time ( another 1-10 or 20), then continue
burn care work , repeating pattern as indicated
62
Managing Pain
Children can enter a shock like state after an injury that can mask their
expressive ability. It is critical to remember that the childs initial experience
with pain sets the stage for the rest of the hospitalization.
Barriers:
Younger children have difficulty conceptualizing or quantifying pain.
Older children have difficulty in describing pain due to lack of experience
Often non-pharmacologic techniques are under -used.
Developmentally Appropriate Interventions
Ages 0-2
Distraction
Ages 2-6
Deep Breathing, Distraction
Ages 6 and older
Deep Breathing, Distraction, Imagery, Progressive
Muscle Relaxation
It is sometimes difficult to predict the most effective pain management for
children with new burns, but providing a dose that gives the maximum coverage
for pain and anxiety is optimal.
Pharmacological Support:
Give IV doses immediately before interventions
Give PO doses 45 minutes to 1 hour before
Frequently used medications and dosages:
Morphine IV
0.1 mg/kg/dose
Fentanyl IV
1-5 mcg/kg/dose
Versed IV
0.05 mg/kg/dose
Oxycodone PO
0.15-0.4 mg/kg/dose
Versed PO
0.5-1 mg/kg/dose
Tylenol
10-15mg/kg/dose
Ibuprofen
10mg/kg/dose
63
64
65
SCARRING
1. Initially it is very difficult to tell how much scarring will be permanent. It
is difficult to predict how much scarring any one person will have since
the amount of scarring is determined on an individual basis and by the
depth of your burn. When you return to clinic you will be evaluated for
the possible need for pressure garments. If you have been grafted
(split thickness skin graft) you will almost always require pressure
garments, all others will be evaluated on an individual basis.
EXERCISE
1. Per physical and occupational therapy instructions.
DIET
1. A healthy, high protein diet is preferable and will promote wound
healing. You may need to supplement your diet with Ensure, Carnation
Instant Breakfast, or other protein shakes.
a. High Protein Food- Dairy (milk, cheese, yogurt, eggs), Poultry, Beef,
Fish (tuna, etc), certain nuts, or Peanut butter.
EMOTIONAL READJUSTMENT
1. If you are having anxiety, sadness, or sleep issues related to this injury
please do not hesitate to call the burn clinic (847-3790) or discuss this
at your next appointment.
FOLLOW-UP
1. Keep all appointments. Burn clinic is located on the 5th Floor of the ACC
building. 847-3790
66
WEBSITE REFERENCES
www.ameriburn.org
www.burnprevention.org
www.burntalk.com
www.nfpa.org
www.burntherapist.com
www.firefightersburninstitute.com
www.cdc.gov
www.traumaf.org
www.shrinershq.org/Hospitals
www.burnsurgery.org
www.sagediagram.com
www.wounds1.com
www.phoenix-society.org
67
68
CC#
Approver Name:
M#:
01/01/2010
Item #
Time Cart
Returned:
New
Item #
Product
PAR ON
CART
Unit of Measure
009291
001988
Hibiclens 16 oz
Sterile Bowls
4
2
bottles
each
55408
Telfa 3 X 8
boxes
001777
001763
Telfa 3 X 2
Ace Bandage 2" non sterile
2
2
boxes
rolls
001764
rolls
001765
rolls
001766
rolls
001839
Kerlix
20
rolls
55418
Lap Sponges
packs
01/01/2001
001872
each
05/01/2010
001873
each
08/01/2010
001874
15
each
001875
each
001878
each
001880
each
001881
each
001882
each
08/01/2010
12/01/2010
001903
59036
Bandnet Size # 3
box
001905
59037
Bandnet Size # 6
box
001906
59038
Bandnet Size # 8
box
001907
59039
Bandnet Size # 10
box
002044
each
020217
12
packs
001771
box
001772
box
55407
rolls
012247
pair
012248
pair
012249
pair
012250
pair
69