Critical Care: Phases of Burn Care

PHASES OF CARE FOR THE BURN PATIENT:

  • Pre-hospital Phase
  • Emergent Phase
  • Acute Phase
  • Rehab Phase

I. PRE-HOSPITAL PHASE – primary concerns are ABC’s (airway, breathing, circulation)

  • Remove from the burn source
  • Check patency of airway and for adequate ventilation
  • Check for adequate circulation
  • Treat as needed – flush the skin for chemical injuries, remove clothing, 100% O2 for carbon monoxide poisoning
  • Prevent hypothermia – only cool for < 10 minutes

II. EMERGENT PHASE – main concerns are hypovolemic shock and edema

  • Airway management: may need intubation R/T edema or swelling of the airway, 100% humidified O2
  • Fluid resuscitation: 2 large bore IVs if 15% burn, central line if 30% burn
    Parkland (Baxter) Formula: 4 mL X kg X % Total Body Surface Area Burned (TBSAB)
    1/2 total in 1st 8 HRS
    1/4 total in 2nd 8 HRS
    1/4 total in 3rd 8 HRS
    Example: For a 70 kg patient with 50% TBSAB → 4 mL X 70 kg X 50 TBSAB = 14,000 mL in 24 hrs
    1/2 total in 1st 8 hrs = 7000 mL (875 mL/hr) ← to calculate, just divde 7000 mL/8 hrs
    1/4 total in 2nd 8 hrs = 3500 mL (437.5 mL/hr)
    1/4 total in 3rd 8 hrs = 3500 mL (437.5 mL/hr)
  • Wound care: debridement, escharatomies (an incision on the skin to relieve pressure due to edema), multiple dressing changes, room needs to be kept warm (85 degrees F), may need artificial skin
  • Pain management: analgesics, nonsystemic antimicrobial agents (Silverlon, Acticoat, Silvadene, Sulfamylon), thromboembolism prophylaxis (Lovenox), tetanus immunization
  • Nutrition: assess gastric residuals frequently, bowel sounds q8h, feedings usually started slowly at 20-40 mL/hr; may give calcium-containing supplements and milkshakes; supplemental vitamins in the emergent phase, iron in the acute phase

III. ACUTE PHASE

  • Wound care: debridement, topical antimicrobial creams (silver sulfadiazine, silver-impregnated dressings)
  • Excision and grafting: after 1-2 days, wound exicsion performed – important to maintain blood conservation and observe for circulation problems, coverage achieved with cultured epithelial autografts (grow skin from the patient’s own cells) or artificial skin
  • Pain management: 2 kinds of pain – background pain and treatment-induced pain, will need continuous IV opioids, around-the-clock management and may be even anxiolytics to potentiate pain relief, patient-controlled analgesia may also be used
  • Physical therapy: maintain joint function and prevent contractures, best times to perform active/passive range-of-motion exercises are during and after wound cleansing; patient’s with neck burns should sleep without pillows or neck dangling off the bed to hyperextend the neck

IV. REHAB PHASE

  • Range of motion exercises
  • Pressure bandages: used to keep scars flat, never worn over unhealed wounds
  • Relieve itching
  • Psychological support: patient may have permanent disfigurement due to scarring, assess for coping skills and family support
Image Source.
Content derived from Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 8th Edition.
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