BURN INJURIES: INITIAL EVALUATION AND EMERGENCY INTERVENTION Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT There are many different types of burn injuries, including those from fire, scalds, electricity, friction, contact with chemicals, and others. The one constant is that people who suffer burns have a desire for minimal scarring and impact to their lives. Emergency intervention is key in returning patients to their lives with minimal scarring and other lasting effects. This course primarily discusses the initial evaluation and emergency interventions associated with burn injuries. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Burn injuries involve acute physiological changes, pain and wound healing that require interventions from the beginning and long after the initial treatment. Health clinicians need to be knowledgeable of the potential and prevention of burn injury complications. Course Purpose To provide health clinicians with knowledge about burn conditions and treatments during the acute emergency setting and throughout a patient’s treatment. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. True or False: Airway edema is generally apparent in the initial burn injury patient and the emergency team must act immediately to stabilize a patient’s airway. a. True b. False 2. During the secondary survey, the health team may uncover injuries not initially apparent in a burn patient, such as: a. Fractures b. Dislocations c. Abdominal injuries d. All of the above 3. An escharotomy involves an incision a. made outside the burned skin using a scalpel. b. deep enough to penetrate the subcutaneous fat. c. to release pressure in the burned area. d. used for debridement of eschar. 4. A Lund and Browder chart is used for: a. estimating the burn extent in a patient. b. estimating fluid loss of a burn patient. c. estimating the range of motion of a burn patient. d. All of the above 5. True or False: Range-of-motion exercises are necessary on a regular basis to promote blood flow to the extremities and to prevent contractures in a burn patient. a. True b. False nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction Burns are a leading cause of injury in the United States. Over one million people seek medical care and treatment for burn-related injuries each year. Burns may range from minor burns, impacting only a small area, to major burns that require months of treatment and rehabilitation. Major burns are a significant cause of disability, morbidity, and mortality among burn victims. The costs associated with caring for individuals with extensive burn injuries are high and the treatment of burns has become highly specialized. Consequently, regional burn centers have evolved into treatment for high-need patients who can be transported to the closest location where specialized care of the burn patient can occur. While regional care services are known to improve the outcome for burn patients, transporting patients to nearby centers that provide comprehensive burn care requires more staff training and understanding of burn injuries during initial patient care and emergency transport. Clinicians who are responsible for assessing, resuscitating, stabilizing, and transporting critical burn patients must be well trained to understand their complex needs and to get them safely to a regional center where their treatment will be continued. Initial Assessment And Rapid Response The initial assessment of a burn patient is a skill that should be learned by clinicians responding to an emergency in the field as well as in the receiving hospital where emergency staff will be working fast to stabilize the patient. Firstly, a patient still in contact with the source of the burn must be removed from that source. In the case of a thermal or electrical burn, the patient should be removed from the area where nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 the fluid or fire took place; if a chemical burn, the person first arriving to the scene should strive to remove as much of the chemical as possible from the patient in order to stop the burning process. This may involve brushing away powders or particles that continue to burn the skin, or flushing the skin or eyes to rinse away caustic chemicals that could still cause damage.1,2 It is important for clinicians to recognize that burn patients can deteriorate quickly, even if they initially seem stable. Clinicians in the emergency setting must assess the patient on a continuous basis and be familiar with the anticipated subtle changes indicating deterioration of the patient before it is too late. Airway Stabilization and C-Spine Immobilization The primary survey of a burn injury involves maintaining a patent airway to facilitate adequate air exchange for the patient. A burn patient may have suffered injuries that could cause the airway to swell and constrict, thereby impeding airflow. Edema formation and airway obstruction can occur quickly with certain types of injuries, such as inhalation injuries, or may develop slowly over time. Because airway edema may not be apparent immediately and develop over a period of time, the clinician must continue to assess and stabilize the airway while providing care for the patient. A patient with burn injuries may have been exposed to some type of gas, smoke, or other materials that were combustible and that can be damaging to the airway and the lungs if inhaled. The heat from the burn source is also damaging to the respiratory tract. The body responds to this exposure with inflammation and swelling, which nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 constricts the size of the airway and can cause obstruction. The patient should be provided with 100% humidified oxygen right away to improve the distribution of oxygen to the tissues while the clinician continues to monitor for changes that suggest an obstructed airway.1 If the patient shows signs of breathing difficulties or obstruction related to airway damage from the burn, endotracheal intubation should be performed as quickly as possible.1 Responders at the scene of the burn or those providing initial care at the hospital should observe for signs of inhalation injury as well as determine from bystanders the nature of the burn potentially affecting the patient’s ability to maintain an open airway; for example, whether the burn injury occurred in an enclosed space. Airway intubation should be performed to support respiratory ventilation while the emergency clinician simultaneously addresses the extent of edema in the patient’s throat. Waiting to intubate a patient’s airway after signs of edema and an obstructed airway develops due to a burn injury may only lead to difficult intubation because in such situations the edema that develops often further constricts the throat and airway passages.1,10 There is a risk of spinal cord injury in situations