Page 671 - ACCCN's Critical Care Nursing

648 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

Breathing minimising exposure, warming fluids and warming the
Carbonaceous pulmonary secretions are a hallmark of patient’s environment. Warm blankets and heated humid-
airway injury. Dyspnoea and tachypnoea are signs of ified supplemental oxygen are also valuable adjuncts.
respiratory distress, while pulmonary oedema will often
ensue with airway burns. Hyperkalaemia
Cell destruction from the burn injury can result in high
Circulation serum potassium levels, which should be monitored
The massive interstitial and intracellular fluid shifts asso- closely. Metabolic acidosis will exacerbate the hyperkalae-
ciated with acute burn injury will deplete circulating mia, as intracellular exchange of hydrogen ions with
volume and result in shock if it remains uncorrected. potassium ions takes place.
Fluid resuscitation aims to anticipate and prevent rather
than treat shock. ANZBA guidelines recommend IV resus- Nutrition
citation in adults with burns >15% TBSA and children Supplemental feeding is mandatory and should com-
with burns >10% TBSA. mence as soon as possible following severe burn injuries
due to the hypermetabolism. Patients with >20% TBSA
Early intravenous cannulation (with two wide-bore can-
nulae) and the administration of high-volume fluids are unable to meet their nutritional requirements orally.
must begin immediately. ANZBA recommends crystalloid ANZBA recommends enteric feeding in adults with burn
solution in the first 24 hours. There are several fluid injury >20% and >10% TBSA in children.
replacement formulas, these are considered as a resuscita-
tion guideline with fluid administration being titrated to The Multitrauma Burns Patient
patient response. One of the most widely accepted resus- Burn is not always an isolated injury, and can occur in
citation formulas is the Modified Parkland formula, that the presence of other trauma (e.g. multitrauma). It is
recommends delivery of Hartmann’s solution at the rate essential to combine the principles of care of the burns
of 3–4 mL/kg/% TBSA over the first 24 hours commenc- patient with those of the relevant injury as outlined:
ing at the time of burn injury, with half the fluid admin- l Spinal injury: if the patient has potential spinal inju-
istered within the first 8 hours and the remainder over ries in addition to the burn, spinal precautions must
the next 16 hours. Time delays for implementation of be maintained; however, cervical collars should not be
fluid resuscitation should be corrected by increasing infu- used over a burnt neck or upper chest due to the
sion rates to reach targets. Fluid resuscitation should be potential for swelling and subsequent restriction. If a
guided by predetermined endpoints in combination with collar is used, changing to an appropriate size as the
fluid volumes dictated by the formula. Precise endpoints swelling worsens or goes down is essential.
for burns resuscitation remain debatable, at present l Skeletal injury: skin traction cannot be used in a
ANZBA recommends urine output of 0.5–1 mL/kg/hr in patient with burn injury over a limb that also has a
adults and 0.5–2 mL/kg/hr in children. skeletal fracture; this will necessitate early internal
Patients with circumferential full thickness burn injury fixation or the use of an external fixateur.
may require escharotomies due to the extensive oedema l Electrocution injuries: electrocution burns are largely
formation and the inelasticity of burn eschar. Delayed internal burns that potentially cause devastating mul-
capillary return, a cool limb and increased pain manifest tiple internal injuries. The electrical current causes a
earlier than loss of palpable pulse. burn at both the entry and exit sites. Where electrocu-
tion is confirmed or suspected the body must be
The use of invasive monitoring in the burns patient is inspected to identify all injuries. These may be in
controversial, as the relevant catheters often require inser- obscure places such as the hands and feet or even the
tion through a burn and therefore provide a portal of back and scalp. Close monitoring for cardiac damage
entry for infection. However, all serious burns patients and rhabdomyolysis is essential.
require an indwelling catheter for monitoring. Relevance
of other monitoring capability will be made on an indi- Burn Dressings
vidual patient basis, based on cardiovascular status, need
for inotropic support, extent of the burn and potential Mitigating infection is the primary aim of good burns
68
for infection. nursing. The greatest challenge is minimising the risk
for cross-contamination, and patients should be nursed
in a single room where possible. Burn dressings present
Minimising hypothermia a physical challenge, particularly when large areas of the
Skin is an essential component of the body’s natural body are affected.
thermoregulation mechanism, so loss of skin integrity, The traditional burn dressing in the ICU is undertaken as
coupled with such treatment strategies as cooling the a surgically clean technique. As part of the management
burn and administering high-volume fluid replacement, of the burn injury, there are a number of specific issues
exposure of wounds following injury and during dressing that require attention. The following is a guide to specific
changes places the patient at high risk of hypothermia. aspects of burn management:
Continuous temperature monitoring is essential, and
strategies to maintain normothermia should be imple- l Debridement: this refers to the excision of dead skin.
mented immediately and continuously. Strategies include Gentle scrubbing is generally used to remove loose