CODE BURNCODE BURNThe First 48 HoursThe First 48 Hours

ByBy

Julie-Ann Airth RN, BAMafalda Concordia, RN

Donna Wood, RRT, BSc. HonJ li K i ht RN MS NJulie Knighton, RN, MScN

Karen Smith, RN, MHSRimona Natanson, pharmacistMelissa Adamson, RN, BScNAnita Au RN MN CNCC(C)Anita, Au, RN, MN, CNCC(C)

Ross Tilley Burn CenterSunnybrook Health Sciences

Objectives: 48 hours Post InjuryObjectives: 48 hours Post Injury

oo Nurse to ADVOCATE Nurse to ADVOCATE for the burn patientso Shatter the Silence

o Aims:

A case review

Current standard of careCurrent standard of care

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O tliOutline1. Case Scenario

2. What to doA t Assessment

o Primary Survey (ABC)o Secondary Survey (Burn)

Interventionso Fluid Resuscitationo Fluid Resuscitation

o Dressing the Burn

3 Transfer3

3. Transfer

Case ScenarioCase Scenario55♂ presents to emergency room after a ball of flames erupted while

attempting to light his barbeque with lighter fluidattempting to light his barbeque with lighter fluid

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Case ScenarioCase Scenario

INJURY b t th f tINJURY: burns to the face, upper torso, bilateral arms and left upper leg

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Primary SurveyPrimary Survey

o COMMON: Use ABCDE approach as with any new trauma A: airway B: breathing C: circulation D di bilit D: disability E: exposure

Id tif d t li h i l th l l t i l to Identify and neutralize any chemical, thermal, or electrical agents which might pose a threat to health care team

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Airway and BreathingAirway and Breathing

o Evaluate upper airway for patency

Inhalational injury

Stridor or dysphagia

Airway compromise Airway compromise

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Airway and Breathingo Evaluate lower airway for comprise

Inhalational injury: increase in secretions, bronchospasm, or

Airway and Breathing

j y , p ,pulmonary edema

o History of injury reveals special considerations Enclosed vs. open space Risk factor for carbon monoxide poisoning

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Airway and BreathingAirway and Breathingo Intubation

Place largest possible uncut ETT

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Airway and BreathingAirway and Breathingo Airway monitoring and work up

Monitor: breathing and chest wall expansion Comorbidities Carboxyhemoglobiny g ABG

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CirculationCirculationo Prepare for extensive fluid resuscitation

2 large PIVs 2 large PIVs Central line

o Check all extremities for pulses

o Elevate! Elevate! Elevate!o Elevate! Elevate! Elevate!

o Check for circumferential burns Risk: compartment syndrome May require escharotomy

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o BP cuff readings may be unreliable Consider arterial line

Secondary Survey: Assess the Burn

o Degree of the Burn

o The Total Body Surface Area (TBSA) affected

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First Degree/Superficial g po Layer: the epidermiso Look: SUNBURNo Feel: Painfulo Heals: 2-7dayso NOT calculated in totalo NOT calculated in total

burn surface area

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Second Degree - Partial Thickness go Layer: epidermis into upper dermiso Look:

• Blister/BullaeBlister/Bullae• Bright red/mottled, moist and

weepingo Feel: extremely painfulo Feel: extremely painfulo Healing: 4-6 weeks

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Second Degree - Deep Dermal g po Layers: epidermis into the dermiso Look: Red with patchy white/yellow

area, and typically dry(usually no blister)

o Feel: Painfulo Heal: up 6 weekso Heal: up 6 weeks

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Third Degree-Full thickness go Layers: Allo Look: Pale white, charred, red or brown,

leathery appearanceo Surface dry o Unblanchable

o Feel: Painless and insensitive o Heal: surgical excision and debridement

Really no pain?

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Total Body Surface Area (TBSA)Total Body Surface Area (TBSA)o an estimate of the extent of burns which are at least 2nd degree or

greatergreaterPalm only, no finger!

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Fluid Resuscitationo Parkland Formula in the first 24 hours post injury (ABLS consensus

Guidelines, 2011)

o Fluid: Ringer’s Lactateo 2-4mL x body weight (kg) x %TBSA

50% l l t d t 1 t 8 h t i j

RATE OF ADMINISTRATION(2 X kg X %burn) [2nd & 3rd Burn added together]

o50% calculated amount 1st 8 hours post injury

o25% second 8 hourstogether]

First 8 hours ½

o25% third 8 hours

½Second8 hours

1/4

Third8 hours

1/4

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1/4 1/4

Case Scenario Part 2

o Audience to apply: TALK TO MY HAND!

Case Sce a o a t

pp y Face Anterior upper torso Both anterior upper limbs Both anterior upper limbs Anterior left upper leg

o Apply the formula RATE OF ADMINISTRATIONpp yo Total TBSA: 40.5%o Weight: 70kg

RATE OF ADMINISTRATION(2 X kg X %burn) [2nd & 3rd Burn added together]

o Fluid required in first 8 hrs: (2mL x 70kg x 40.5%)/2

First 8 hours ½

Second Third

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= 2.84L in 8 hours= 354cc/hr

8 hours1/4

8 hours1/4

Monitoring the ResuscitationMonitoring the Resuscitation

o Guide Fluid Resuscitation: insert a urinary catheter

o Urine output targetsoo Adult Thermal and Chemical burns: 30Adult Thermal and Chemical burns: 30 -- 50 ml urine/hour50 ml urine/houroo Adult Thermal and Chemical burns: 30 Adult Thermal and Chemical burns: 30 -- 50 ml urine/hour50 ml urine/houro Adult High Voltage Electrical burns: 75 - 100 ml urine/hour

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Fluid Shift and EdemaFluid Shift and Edema

• Fluid shift and edema formation peaks 24-48hrs post injury

• Fluid mobilization (18-36hrs post injury)

• Fluid resuscitation– General/Localized edema – 20% weight gain from retained resuscitation fluid g g– Interstitial fluid volume may lead to an in compartment pressures

– Pay close attention to circumferential burns and regularly assess CSM and pulsePay close attention to circumferential burns and regularly assess CSM and pulse

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Analgesia in Burns

o Assess

Analgesia in BurnsUNIVERSAL: inadequate pain treament

o Assess Visual Analogue Scale Numeric Rating Scale Critical Care Pain Observation Tool Critical Care Pain Observation Tool

oNon-PharmacologicDistractionDistractionGuided ImageryRelaxation Virtual Reality

oPharmacologic Opioid analgesicsAdj t

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Adjuncts

Dressing The Burn: COMPLICATED?Dressing The Burn: COMPLICATED?

o 1. Clean

o 2. Debride nonviable sloughing tissue.

o 3.Dress Silver Sulfadiazine-topical antimicrobial agent

4 Wo 4.Wrap wrap the affected area with NS wet to dry gauze and secure with kling. Wrapping distal to proxmial

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Dressing The Burn: SIMPLEDressing The Burn: SIMPLE

oo CleanClean Clean wound with warm Normal Saline

oo Normal Saline Soaked Normal Saline Soaked Wet to dry dressing

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Indications for Transferd cat o s o a s e

1. Partial thickness >10% TBSA

2. Burns: to face, hands, feet, genitalia, perineum, or major joints.

3. Third degree burns

4 El i l b4. Electrical burns

5. Chemical burns

6. Inhalation injury.

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Indications for Transfer (cont’d)Indications for Transfer (cont d)7. Pre-existing medical disorders that complicates management

8. Burn & Trauma (such as fractures)

9. Burned children in hospitals WITHOUT qualified personnel/equipment

10. Burn patients requiring social, emotional, or rehabilitative intervention.

26 Handout available!!!Handout available!!!

Case ScenarioCase Scenario

55♂ presents to emergency room after a ball of flames erupted p g y pwhile attempting to light his barbeque with lighter fluid

INJURY: burns to the face, upper torso, bilateral arms and left upper leg

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Case Scenario Part 3Case Scenario Part 3INJURY: burns to the face, upper torso, bilateral arms and left upper leg

GOAL: Stabilize, Monitor and Dress

Airway

What do we need to do or assess?Intubate

Breathing

Circulation (and lines)

Pulse check q1h (U/S doppler)Lines(Arterial and CVL/PIV’s)VS q1htemp. q4h

Fluid

Dressing

Fluid:Parkland formulaU/O q1hCVP q1h

Dress: NS soaked wet to dryOthers

Dress: NS soaked wet to drypain control

OtherBladder pressures q4hNG/OG/Post-pyloric

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Transfer

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Bloodwork: lactate, carboxyhemaglobin, and ABG

Arrangement for transport to burn unit

AchievementAchievementCare of burn patients prior to transfer to the Burn Centre

Main Goal

• Quick Review/Sharing our knowledge with our fellow colleagues

• Break the barrier between Critical Care and “Burn Care”• Break the barrier between Critical Care and Burn Care

• Always available, CALL

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QUESTIONS?QUESTIONS?

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Referencese e e ces

1. ABLS 2011 Provider Manual Ch. 9 Stabilization, Transfer and Transport. P. 97-103.2 B D C t htt // h lth lb t /h lth/P / diti ?h id b A d2. Burn Degree Cartoons. https://myhealth.alberta.ca/health/Pages/conditions.aspx?hwid=burns. Accessed

June 11, 2013.3. Cartotto, R. (2009). Fluid Resuscitation of the Thermally Injured Patient. Journal of Clinical Plastic Surgery

36. p. 569-5814 Connor Ballard P (2009) Understanding and managing burn pain: Part I American Journal of Nursing4.Connor-Ballard, P. (2009). Understanding and managing burn pain: Part I. American Journal of Nursing,

109(4), p. 48-56. 5. Herndon, D. (2007). Total Burn Care. Philadelphia, Elsevier Saunders.Latenser, B (2009). Critical care of the burn patient: The first 48 hours. Critical Care Medicine, 37(10),

2819-2826.6. Oliver, R., del la Torre, J. (2012). Burn resuscitation and early management.

http://emedicine.medscape.com/ article/1277360-overview7. Urder, L., Stacy. K, & Lough, M. (2010). Critical Care Nursing: Diagnosis and Mangagement. Chapter 41:

Burns. Elsevier, St. Louis, Missouri.

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