i bc27f85be50b71b1 (138 page)

A

Partial

A

'"

Hair shaft

>

()

Epldennl.-{

Denn�-{

()

>

"

m

Z

0

Sweat

�

0

gland

0

r.

�

Bone

0

"

(a) Superflcial bum

(b) Partial thickness bum

�

partiel{

J:

-<

�

�

r

i!

Deep

m

thickness

Full

�

bum

thickness

�

bum

(e) Deep partial thickness bum

(d) Full thk:kness bum

Figure 7-5. The depth o( bum inJuries (rom fA) superficial to (D) (ull thick"ess. (With permissio" (rom M Walsh [edt. Nurse Practitioners: Clmical Skills and Pro(essional Issues. Oxford, UK: Butterworth-Heinemann, 1999;28.)

Table 7-5. Burn Depth Characteristics

Deprh

Appearance

Healing

Pain

Su perficial (first-degree)-epidermis

Pink to red

3-5 days by epithel

Tenderness to

injured

With or without edema

ialization

tOuch or

Dry appearance without blisters

Skin appears intact

painful

Blanches

Sensation intact

Skin intact when rubbed

Moderate partial-thickness (second

Pink ro mortied red or red with edema

5 days to 3 wks by

Very painful

degree)-superficial dermis injured

Moist appearance with blisters

epithelialization

Blanches with slow capillary refill

Pigmentation changes

Sensation intact

are likely

Deep partial-thickness (second

Pink ro pale ivory

3 wks to mas by

Very painful

degree)-deep dermis injured with

Dry appearance with blisters

granulation tissue

hair follicles and sweat glands

May blanch wirh slow capillary refill

formation and

intact

Decreased sensation ro pinprick

epithelialization

Hair readily removed

Scar formation likely

�

Full-thickness-entire dermis injured

White, red, brown, or black (charred if

Not able to regenerate

No pain, perhaps

�

(third degree) or fat, muscle, and

fourth degree)

an ache

�

>

bone injured (fourth degree)

Dry appearance without blanching

5

May be blistered

"

Insensate to pinprick

Depressed wound

�

Source: Data from P Wiebelhaus, SL Hansen, Burns: handle with care. RN 1999;62:52-75.

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450 ACtJTE CARE HANDBOOK FOR I'HYSICAI. nIERAI'ISTS

care is optimal for the patient. The American Burn Association recommends medical care at a burn center if the patient has any of the following":

•

Second- and third-degree burns that are greater than or equal to

10% of TBSA in patients younger than I 0 years of age or older

than 50 years of age

•

Burns of any type that are greater than 20% of TBSA in patients

between 10 and 50 years of age

• Full-thickness burns that are greater than or equal to 5% of

TBSA

•

Second- and third-degree burns of the face, hands, feet, genitalia, perineum, or major joints

•

High-voltage electrical or lightning injury

•

Inhalation injury or other trauma

•

A significant chemical burn

•

Pre-exisring disease in which rhe burn could increase morraliry

Resuscitative Phase

The objectives of emergency room management of the patient who has

a major burn injury include simultaneous general systemic stabilization and burn care. The prioritization of care and precautions during this initial time period have a great impact on survival and illustrate

some key concepts of burn care. General systemic stabilizacion involves

( 1) the assessment of inhalation injury and carbon monoxide (CO)

poisoning and the maintenance of the airway and vemilation with supplemental oxygen (see Appendix III-A) or mechanical ventilation (see Appendix lII-B), (2) Auid resuscitation, (3) the use of analgesia (see

Appendix VI), and (4) the treatment of secondary injuries.16

Inhalation In;ury and Carbon Monoxide Poisoning

The inhalation of smoke, gases, or poisons, which may be related to

burn injuries, can cause asphyxia, direct cellular injury, or both. Inhalation injury significantly increases mortality and varies depending on the inhalant and exposure time. There is no strict definition of inhalation injury. Inhalation injury is suspected if the patient was exposed to noxious inhalants, especially in an enclosed space, or if the patient