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American Pediatric Surgical Nurses Association

One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org

25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA

1

Burn Care

Carrie Wilson, RN, CPNP-PC, CPNP-AC, WCC Washington University / St. Louis Children's Hospital

St. Louis, MO

Disclosure Information

There were no financial interests or relationships or conflicts of

interest to disclose for any of the Burn Care roundtable

moderators.

Objectives

1) Describe different techniques used to assess burn size and depth of pediatric burn patients after stabilization.

2) Describe appropriate cleansing and debridement techniques of pediatric burn injuries and utilization of ancillary services (i.e. pain control, sedation, child life, therapy) for these procedures

3) Describe current topical treatment/dressings for pediatric burns that offer the best wound coverage and infection control.




2

Burn Incidence

• Burn injuries that require medical treatment annually-450,000 per year.

• Burn injuries requiring hospitalization total approximately 40,000 per year.

• 60% of these patients are admitted to one of the 128 specialized burn centers in the United States.

Multidisciplinary Approach

3 Core FT RNs (Increasing)

FT Nurse clinician

FT PNP

Cross-trained 10th floor nurses

Program Assistant

Hospitalist

PT/OT

Child Life

Nutrition

Pharmacy

Physicians

CPT

Social Work




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Pathophysiology: 3 Zones of Injury

(1) zone of coagulation

(2) zone of stasis

(3) zone of hyperemia

Classification

• Superficial

• Superficial partial thickness

• Deep partial thickness

• Full thickness

Size of the Burn

• Calculating Total Body Surface Area (TBSA)

• Lund Browder calculation performed at Burn dressing change

• Partial to Full thickness burns only

• Pediatrics have disproportioned body type

• Patients Palm + Fingers = 1% TBSA




4

Depth of the Burn

First Degree Burn

Superficial

Painful

No blistering

Pink; red

Mild edema

Blanches with pressure

Partial Thickness (2nd degree)

Pink to red

Moist

Moderate edema

Extremely painful

Vesicles




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Partial Thickness

Partial Thickness

Superficial Partial vs. Deep Partial Thickness Burns




6

Hand Burn-Deep Partial Thickness

Full Thickness (3rd Degree)

Waxy-white to black

Dry leathery

Thrombosed vessels

Edema

Painless

Doesn’t blanch with pressure

Types of Burn Injury

• Thermal

• Electrical

• Chemical

• Various treatment modalities for each




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Partial vs. Full Thickness

Flame Burn

Debridement

Manual

Sharps Debridement

Consent

Including Iris scissors and/or Curette




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Pre-Debridement

Post-Debridement

Calculating TBSA

• Partial to full thickness burns only

• Patients Palm + Fingers = 1%

• Lund-Browder chart




9

Typical Dressing Change

Make child comfortable (Child Life)

Provide sedation if needed/Adminster pain meds according to institution

Transition to treatment room

Rally the troops

Consent, Timeout, Sedate


Radiant warmer on

Remove old dressing (note any cellulitis, foul-smelling drainage, s/s infection)

Assess wound

Debride (manually or with sharps)

Debride blisters over joints

Gentle cleansing (if burn is already post-debridement, with soap and water)

Provide education

Document




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Measure/estimate burn size using Lund-Browder, document %

Picture (according to institution policy)

Range of Motion with PT/OT at bedside with dressings off while sedated (is optimal)

Implement dressing

Schedule f/u

Tub Time

PAWS-Experienced Wound Care




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Taking the “Ouch” Out

Nitrous

Ketamine

Versed

Tylenol

Oxycodone

Percocet

Most Common Dressings

Silvadene Cream

Antimicrobial Cream

Apply 1-2 per day

Easy to Apply

Leaves a film on wound requiring cleansing




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Silver Impregnated Foam Dressings

Foam dressing impregnated with Silver

Silver helps fight infection

Easy removal

Absorbant

Compresses

May leave on several days

Silver Impregnated Foam Dressings




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Foam Dressing

Foam dressing

Silicone contact layer

No pain or trauma upon removal

Waterproof outer layer

Silver Impregnated Dressing (Aquacel AG)

Silver impregnated dressing

Feels like felt

Absorbs exudate and forms a gel

Fills the wound and traps the bacteria

Silver Impregnated Dressing




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Silver Impregnated Rope Dressing

Antibiotic Ointment

Xeroform

Petroleum based dressing

Antimicrobial

Protective dressing




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Non-Adherent Gauze (Telfa)

Tubigrip

Kerlix & Conform




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Ace wrap

Complicated Burns

Escharotomy




17

TE & Pigskin

Pigskin Graft

Oasis Wound Matrix

Small intestine submucosa (SIS)

Reduces the likelihood of patient rejection due to its natural acellular yet intact extracellular matrix composition




18

Muffler Burn

Muffler Burn post debridement

Pre and Post STSG




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STSG

Donor Site s/p STSG

Physical and/or Occupational Therapy




20

S/P STSG

Burn Clinic

Compression




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Severe Contracture

When to Refer to a Burn Center

1. Partial thickness burns greater than 10% total body surface area (TBSA).

2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.

3. Third degree burns in any age group.

4. Electrical burns, including lightning injury.

5. Chemical burns.

6. Inhalation injury.

7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.

When to Refer to a Burn Center

8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.

9. Burned children in hospitals without qualified personnel or equipment for the care of children.

10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention

(ABA, 2016)




22

References

American Burn Association. Burn Incidence and Treatment in United States Fact Sheet. http://www.ameriburn.org. 2016. Accessed March.

Haines, et al. Optimizing emergency management to reduce morbidity and mortality in pediatric burn patients. Pediatric Emergency Medicine Practice. 2015: 12 (5): 1-24.

Ellison, DL. Burns. Critical Care Nursing Clinics of North America 2013: 25:273-285.

E.L. Gee Kee, R.M. Kimble, L. Cuttle, A. Khan, K.A. Stockton .(2015). Randomized controlled trial of three burns dressings for partial thickness burns in children. Burns, 41(5), 946-955. doi:10.1016/j.burns.2014.11.005

Jeschke, MG, et al. Morbidity and survival probability in burn patients in modern burn care. Critical Care Medicine 2015: 43 (4): 808-815.

Lloyd E, et al. Outpatient burns: prevention and care. Am Fam Physician. 2012;85(1):25.

Mckenna, C., Pieper, P. (2013). Chapter 31: Pediatric trauma. In N.T. Browne and others (Eds.), Nursing care of the pediatric surgical patient (3rd ed., pp. 513-538). Burlington, MA: Jones & Bartlett Learning.

Seigel, J., Wilson, C.M., McCubbins, M. (2014). Chapter 36: Burns. In L.D. Urden, K.M. Stacy, M.E. Lough (Eds.), Critical care nursing: Diagnosis and management (7th ed., pp. 926-950). St. Louis: Mosby.

Thank you!

http://www.ameriburn.org/

http://www.sciencedirect.com/science/article/pii/S0305417914003763

http://www.sciencedirect.com/science/article/pii/S0305417914003763

http://dx.doi.org/10.1016/j.burns.2014.11.005

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