Burns

Etiology:Thermal burns may result from any external heat source (flame, liquids, solid objects, or gases). Radiation burns most commonly result from prolonged exposure to solar ultraviolet radiation (sunburn) but may result from prolonged or intense exposure to other sources of ultraviolet radiation (eg, tanning beds) or from exposure to sources of x-ray or other nonsolar radiation. Chemical burns may result from strong acids, strong alkalis (eg, lye, cement), phenols, cresols, mustard gas, or phosphorus. Electrical burns (see also Electrical and Lightning Injuries: Electrical Injuries) result from the electrical generation of heat; they may cause extensive deep tissue damage despite minimal apparent cutaneous injury. —Gina Anthony

Signs/Symptoms:First-degree burns are red, blanch markedly and widely with light pressure, and are painful and tender. Vesicles or bullae do not develop.

Superficial partial-thickness burns blanch with pressure and are painful and tender. Vesicles or bullae develop within 24 h. The bases of vesicles and bullae are pink and subsequently develop a fibrinous exudate.

Deep partial-thickness burns may be white, red, or mottled red and white. They do not blanch and are less painful and tender than more superficial burns. A pinprick is often interpreted as pressure rather than as a prick. Vesicles or bullae may develop; these burns are usually dry.

Full-thickness burns may be white and pliable, black and charred, brown and leathery, or bright red because of fixed Hb in the subdermal region. Pale full-thickness burns may simulate normal skin except the skin does not blanch to pressure. Full-thickness burns are usually anesthetic or hypoesthetic. Hairs can be pulled easily from their follicles. Vesicles and bullae usually do not develop. Sometimes features that differentiate full-thickness from deep partial-thickness burns take a few days to develop. —Gina Anthony

Method of Diagnosis:Because findings evolve rapidly, burns are examined as soon as patients are stable. Location and depth of burned areas are recorded on a burn diagram. Burns with an appearance compatible with both deep partial-thickness and full-thickness are assumed to be full-thickness until differentiation is possible. The percentage of BSA involved is calculated; only partial- and full-thickness burns are included in this calculation. For adults, the percentage BSA for parts of the body is estimated by the rule of nines. The rule of nines for adults: head and neck= 9%, arm (each)= 9%, trunk (anterior and posterior each)= 18%, leg (each)= 18%, genitalia= 1%. For smaller scattered burns, estimates can be based on the size of the patient's palmar hand surface, which is about 1% of BSA. Children have large heads and small thighs, so the percentage BSA is more accurately estimated using the Lund-Browder chart.

If patients require hospitalization (see Burns: Initial treatment), Hb and Hct, serum electrolytes, BUN, creatinine, albumin, protein, phosphate, and ionized Ca should be measured; ECG, urinalysis for myoglobin, and chest x-ray are also required. Myoglobinuria is suggested by urine that is grossly dark or that tests positive for blood on dipstick in the absence of microscopic RBCs. These tests are repeated as needed.

—Gina Anthony

**Risk Factors:
*Modifiable: coming in contact with fire, hot objects, steam, highly acidic liquids, strong alkalis, phenols, cresols, mustard gas, or phosphorus, live electrical wiring, prolonged exposure to sun, tanning bed, x-ray
*Non-Modifiable: pale sensitive skin, being struck by lightening
—Gina Anthony

Prevention:Avoid coming in contact with fire, hot objects, steam, highly acidic liquids, strong alkalis, phenols, cresols, mustard gas, or phosphorus, live electrical wiring, prolonged exposure to sun, tanning bed, x-ray. Wear sunscreen (SPF 15 or higher); avoid being outside when it's lightening.
—Gina Anthony

Supplements Commonly Used:Treatment of electrolyte deficits may require supplemental Ca, Mg, K, or phosphate (PO4). Maintenance of adequate fluid intake and urine output. —Gina Anthony

Labs Appropriate to Disease:
*Normal Values Range:Prealbumin-18-38, Albumin-3.5-5.0 gm/dL, Na+-135-148mEq/L, Protein-1-15mg/dL
*Values in the Disease:High- Protein, High- Albumin -Kelly Delph
*Nutritional Significance:

General Dietary Prescription:
Nutrition Support is recognized as one of the most significant aspects of care for the burned patient. Weight loss is a common complication in the burn units. Wound healing occurs at an anabolic state. After resuscitation is complete, feedings should be initiated. Very early eternal feedings (within 4-12 hours of hospitalization) has been shown to be successful in decreasing the hypercatabolic response this decreases the release of catecholamine glucagons, weight loss, and shortens the hospital stay for patients with major burns. Most patients with burns of less than 20% TBSA are able to meet their needs, with a regular high-calorie, high-protein diet. -Kelly Delph

Specific Foods to Include:
High-protein foods, high-calorie foods that are tolerable and within the patients, restrictions (ex. Diabetes, hypertension) if there are any. Milk, cottage cheese, yogurt, Ice Cream, cream soups, eggs, meat, chicken, fish, beans. -Kelly Delph

Specific Foods to Avoid:
“diet” foods—Kelly Delph

Reccomended Prescription Drug Therapy:
Different burns require different treatments and medications. Thermal Burns are recommended with analgesics, NSAIDS, topical antibiotics (silvadene). Chemical Burns require antibiotics, analgesics, and NSAIDS. Electrical Injuries require fluids and osmotic diuretics. Scar treatment meds are Maderma-3-4 times a day for 3-6 months. Cica-Care gels sheets-flattens and softens scars, self-adhesive, 1 sheet can last up until 28 days.——Kelly Delph

Potential Food and Drug Interactions:
depends on the individual-Kelly Delph

General Nutrition Education Objectives or Goals:
1.) minimize metabolic response by: controlling environmental temperature, maintaining fluid and electrolyte balance, controlling pain and anxiety, and covering wounds early. 2.) Meet nutritional needs by: providing adequate protein for positive nitrogen balance and maintenance or repletion of circulating proteins, providing vitamin and mineral supplementation as indicted. 3.) Prevent curlings ulcer by providing antacids or continuous enteral feedings. -Kelly Delph

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