Taggart on burns uncovered then covered 2
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Transcript of Taggart on burns uncovered then covered 2
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Sue TaggartCNC Burns SupportCRGH
BURNS UNCOVERED
COVERED
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Assessment of burns % Total Body Surface Area burntBurn depth
Initial management of the burn woundImportance of burn wound closureDescribe acute burn wound products
BURNS UNCOVERED - COVERED
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TOTAL BODY SURFACE AREA (TBSA) RULE OF 9’S
Palmar MethodPalm & fingers of the patient = 1% TBSA
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LUND AND BROWDER
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5
Epidermis
Dermis- capillaries- nerves
Fat
Epidermal
Superficial Dermal
MidDermal
DeepDermal
Full Thickness
Assessment of Burn Depth
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SUMMARY OF BURN DEPTH ASSESSMENT
©EMSB
Depth Colour Blisters Cap Refill
Sensation
Healing
Epidermal
Red No Present Present Yes
Superficial Dermal
Pale Pink
Small Present Pain + Yes7-10d
Mid-dermal
Dark Pink
Present Sluggish Pain + Usually21d
Deep Dermal
Blotchy Red
+/- Absent < Pain >3 wks
Full thickness
White No Absent <Pain No
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Assess tissue perfusion- Blanching & capillary refill
BURNS UNCOVERED - COVERED
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BURNS UNCOVERED - COVERED
Zone of injury – (stasis)Zone of stasis
Jacksons Burn Model
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BURNS UNCOVERED - COVERED
Assess co morbidities
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BURNS UNCOVERED - COVERED
Day 5
Day 1 - 86yr F 18% bath scald
Day 10
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BURNS UNCOVERED - COVERED
LOOK
DO
AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXPOSURE
FLUIDSANALGESIATESTSTUBES
Assess TBSARule of 9’sIV FluidsParkland formulaIDC/NGIV OpioidsEUC/FBC/ABG/COAGXrays
A.M.P.L.E. History
Head to Toe Examination
EscaharotomyTetanus
Documentation and Transfer
Support
C spine O2Haemorrhage
control I.V.AVPU & Pupils
Environmental Control
Primary Survey First Aid Secondary Survey
Emergency Management of Severe Burns (ANZBA 2014)
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First Aid will provide pain relief as it decreases the inflammatory response, oedema, decreases cell damage◦Cold tap water 20 minutes, within 3hrs injury◦Aware of hypothermia (Cuttle and Kimble 2010)
BURNS UNCOVERED - COVERED
Cold tap water Burn Aid™
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BURNS UNCOVERED - COVERED
Escharotomy
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/Burns_Transfer_Guidelines_2013-14_-_web.pdf
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Analgesia / sedation
BetadineIncise medially
/laterally avoiding nerves/veins
Calcium alginateAntimicrobial
dressing
BURNS UNCOVERED - COVERED
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BURNS UNCOVERED - COVERED
Prontosan -.1 % Betaine (surfactant) and Polihexamethylene Biguanide PHMB (antimicrobial ) $12. 50 bottle
Efective against Staphylococcus aureus, methicillin-resistant S. aureus, S. epidermidis, Pseudomonas aeruginosa, Escherichia Coli, and Klebsiella pneumonia,Anti fungal
Cleansing
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BURNS UNCOVERED - COVERED
Epidermal burn/1°/ErythemaPain, red, intact, heal within <7 daysMoisturise, protective dressing
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BURNS UNCOVERED - COVERED
Cleanse, silicone dressing eg Mepilex Lite™, retain with hypafix, elevate
Superficial dermal/2°/Superficial Partial
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BURNS UNCOVERED - COVERED
Mid Dermal / 2 ° / Partial Thickness/ heals 7 - 10 days
Incise blister, leave epidermis intact . 5% chlorhexidine with paraffin gauze Bactigras. - $12 roll
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BURNS UNCOVERED - COVERED
Deep Dermal burn /2°/Deep partial thickness burnPink/white, pain , capillary refill >3 seconds. 2 - 3 weeks to heal, may require a graft
Hydrocolloids dressings• gelatin, pectin, carboxymethylcellulose• Facilitates autolytic debridement
Examples, Duoderm, comfeel wafer (10 x 10 cm2 $3.40 )
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BURNS UNCOVERED - COVERED
Full thickness burns / 3° white, leathery, charred, cherry red, no capillary refill, requires grafting
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BURNS UNCOVERED - COVERED
• Day 4 post flame burn• 93 yr old • 20% burn
Full Thickness Burn / 3 °
Silver - Acticoat™
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Nano crystaline silver Acticoat™ 40cm x 40cm $164Reduces bacterial count by blocking
the respiratory enzyme system and impairs DNA replication
two layers of high-density polyethylene silver net with an inner layer of rayon
Broad spectrum antimicrobial including gram pos/neg, MRSA, anti fungal
slowly releases silver over 2 – 3 days if kept moist with water
BURNS UNCOVERED - COVERED
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BURNS UNCOVERED - COVERED
Cling wrapMepilex Lite™ Solosite gel™
Hypafix™ border /sprayMoist kerlix™H2O
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BURNS UNCOVERED - COVERED
BiobraneTemporary skin substitute
Day 1 – Contact burn 7% Dermal burnInk cartridge exploded when thrown into fire
Cost $41.17 per 100cm2 13cm x 38cm = $223 medium glove = $800
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BURNS UNCOVERED - COVERED
10 days post burn
Biobrane: The use of biosynthetic dressings is associated with a improved healing and a reduction in pain during burn dressings changes (Level I evidence Wasiak , 2009 Cochrane review)
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BURNS UNCOVERED - COVERED
Early Excision and Split Skin Grafting
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BURNS UNCOVERED - COVERED
SSG applied after debridement and surfasoft appliedSurfasoft - polyamide transparent dressing$3.48 100cm2
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BURNS UNCOVERED - COVERED
3 days post graft, surfasoft intact, reduces shearing allows exudate to move from wound to outer dressings
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Burns uncovered - covered
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BURNS UNCOVERED - COVEREDAutologous SSG Allograft – donor screenedArrive frozen – 135c cryopreserved and streptomycin & penicillin. Thawed, rinsed, applied40% TBSA $19,925
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BURNS UNCOVERED - COVERED
Kaltostat - $2.73 10 x 10 cm 2Calcium/Sodium Alginateabsorbent haemostatic fibre
Aquacel Ag $20.07 10cm2Broad spectrum CMC fibre
Mepilex Transfer $ 7.42 10 x 10 cm
Duoderm $2.34 10 x 10 cm
Donor Sites
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BURNS UNCOVERED - COVERED
93 yr femaleDay 10 post flame burnDay 1 post op, SSG, BiobraneDay 15 deceased
Surgery – early excision ?
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BURNS UNCOVERED - COVERED
Day 5 post full thickness burn – delay in surgeryFlammacerium applied. Flammazine provides Antimicrobial cover and the cerium nitrate hardens the eschar – reduces inflammatory Response
Flammacerium
Flammazine plus Cerium Nitrate$295 tub
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Negative Wound Pressure TherapyVACFoam $60, Cannister $65, Rent $65 day
Burns uncovered - covered
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BURNS UNCOVERED - COVERED
Discharge7 days post surgery 10 days post surgery
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BURNS UNCOVERED - COVERED
Full thickness burn Neo Dermis applied - Pelnac™
7 days post Pelnac 6 months post surgery
53 days post Pelnac25 days post SSG
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Conclusion Assess % Total Body Surface Area
Rule of 9’s in the initial primary assessment Lund and Browder Chart
Assess depth History Clinical examination - colour Capillary refill
Burn wounds are dynamicTopical wound management can aid wound healing,
control microbial activity, reduce pain Early excision of full thickness burn ideal
BURNS UNCOVERED - COVERED
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a nurse participant in Rudge’s (1998) study explained “... i t ’s such a horrif ic area to work in, visually... deal with the wound, wrap it up and they’re a person again”
Mother of 21-year-old (32% flame burn) explained (Gull ick et al 2014),
“ It took my breath away. It took everything I had not to cry... I had to think ‘This is your child, he’s no different’...
A patient who had sustained a 36% flame burn (Skylas, Taggart, Gull ick 2014)
‘ I ts hard and traumatic experience. I just wanted to get knocked out and just forget about it ’ .
BURNS UNCOVERED - COVERED
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1. Herndon 2014 . Tota l Burn care Herndon, D. Tota l Burn Care, 2012. Forth Edi t ion. Harcourt L td
2. Latenser B 2009. Cr it ica l Care of the burns pat ient : the first 48hrs: Cri t ica l Care Medic ine Vol 37 no. 10
3. Cutt le L and Kimble R. (2010) First a id t reatment of burn in jur ies . Wound Pract ice and Research, Vol. 18, No.1.
4. Orgi l l , D. P. and Piccolo N. , Escharotomy and decompression therapies in burns. J Burn Care and Research, 2009. 30(5) :p .759-68
5. Wasiak J , C le land H, Campbel l F. (2009) Dress ings for superficia l and part ia l th ickness burns (Review). The Cochrane Col laborat ion. I ssue 1.
6. Macintrye PE, Scott DA, Schug SA, Visser E J , Walker SM. (2010) Acute pa in management: Sc ient ific evidence. Austra l ian and New Zealand Col lege of Anaesthet is ts .
7. Greenwood JE, C lausen J , Kavanagh S. (2010) Exper ience with Biobrane; uses and caveats for success. Wound Pract ice and Research, Vol .18, No. 1 , pp 50-56.
8. http: / /www.aci .hea lth .nsw.gov.au/__data/assets/pdf_file /0004/162634/Burns_Transfer_Guide l ines_2013-14_-_web.pdf
9. Gu l l ick J , Taggart S , Johnson R, Ko N 2014, The Trauma Bubble: Pat ient and fami ly exper ience of ser ious burn in jury, Internat iona l Journal of Burn Care and Research.
10. Rudge T. Sk in as cover: the d iscurs ive effects of 'cover ing ' metaphors on wound care pract ices . Nurs Inq 1998;5:228-237.
BURNS UNCOVERED - COVERED
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Biobrane and Full thickness burns
Burns uncovered - covered
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BURNS UNCOVERED - COVERED
Day 5
Day 1 - 86yr F 18% bath scald
Day 10
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DOMESTIC BATHROOM SCALDS IN THE ELDERLY
• When elderly patients were ‘not fit for surgery’ the use of Versajet ™ successfully removed adherent burn tissue
• Treatment continued with the application of hydrocolloids which supported autolytic debridement and epithelialisation
Patient D 12 weeks post burn 4 weeks post Versajet ™
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BURNS UNCOVERED - COVERED7/9/12 Day 5 post burn day 2 post debridement Biobrane
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BLISTER MANAGEMENT
Option 2- Incise blister
Day 1 Deep dermal burn - hot water scald
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BLISTER MANAGEMENTOption 2 – Incise blister, Acticoat application
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DEEP PARTIAL THICKNESS BURN
Comfeel wafer™
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Acticoat Metallic nano crystaline silver Broad spectrum antimicrobial
including gram pos/neg, MRSA, Fungi
minimizing the bacterial colonization of wounds
800 mcg/day Agryia Reacts much more slowly with
chloride and thus is deactivated less rapidly in wounds – change every 2 -3 days
Silvazine/Flammazine Ion ic s i lver Active against Gram neg and
positive bacteria minimizing the bacterial
colonization of wounds Forms a pseudo-eschar over
burn 3025 mcg/day rapidly deactivated by wound
exudate (especially chloride ions), thus requiring daily application
Contains sulphur - al lergies Slows wound healing ( Wasiak
2009 The Cochrane Col laborat ion)
BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN
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BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN
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Hypoperfusion: Full thickness burn - can not expand (protein denaturation and oedema). Perfusion is reduced therefore necessary to release burn surgically - escharotomy
CASE STUDY: KUNUNURRA
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BURNS UNCOVERED THEN COVERED
Neuropathic Pain- Hyperalgesia, Allodynia
◦ Anti convulsants e.g. Gabopentin ◦ Anti depressants e.g.
Amitriptaline◦ Paracetamol◦ Tramadol8 days post contact burn
7 weeks post burn18 days post burn
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Burn Wound dressings, Skin Substitutes and Bioengineered Skin
Donor sitesDuoderm $2.34 10cm2Mepilex Transfer $7.42 10cm2
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BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN
BIOBRANE• Outer silicone membrane with a nylon fabric • Porcine collagen incorporated into both layers which aids adherence to the wound•. Temporary protective semi permeable skin substitute•
Partial Thickness burns/Dermal Burns
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BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN
Cultured Epithelial Autografts - CEA
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Skin biopsy for Cultured Epithelial AutograftsCEA
Burn Wound dressings, Skin Substitutes and Bioengineered Skin
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Triad of critical careHypothermia 33 ⁰cvasoconstriction/hypoperfusionCoagulopathy (ineffective platelet function)
Myocardial performance Impairment of wound healing
(Fredrikson 2011)
BURNS UNCOVERED - COVERED
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57
WOUND PROGRESSION
Day 1 post burn
Day 3
Day 7 post burn, day 4 post Biobrane
74 yr old female, hot water scald
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“My head looked like The Elephant Man... On the end of my shoulders was this thing like a Star Wars movie. It was disgusting… I was so embarrassed… my head blew up, so as the night went on I became uglier and uglier. It was like nothing I’d ever seen”
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Wound healing trajectory
BURNS UNCOVERED - COVERED