Burns: Management of Burns- Acute or Intermediate phase

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2. Acute phase/ Intermediate phase
Table : Fluid and Electrolyte Changes in the Acute Phase
Fluid remobilization phase (state of diuresis)
Interstitial fluid → plasma
OBSERVATION

EXPLANATION
Hemodilution
(decreased hematocrit)
Blood cell concentration is diluted as fluid enters the intravascular compartment; loss of red blood cells destroyed at burn site

Increased urinary output

Fluid shift into intravascular compartment increases renal blood flow and causes increased urine formation.

Sodium (Na+) deficit

With diuresis, sodium is lost with water; existing serum sodium is diluted by water influx.

Potassium (K+) deficit (occurs occasionally in this phase)

Beginning on the fourth or fifth post-burn day, K+ shifts from extracellular fluid into cells.

Metabolic acidosis
Loss of sodium depletes fixed base; relative carbon dioxide content increases.

  • Duration: From beginning of diuresis or mobilization of extra-celluar fluid to near completion of wound healing/closure. This may take weeks or many months.
Goals :
  • Prevention infection: hand washing, control of visitors
  • Treatment of complications

Interventions in acute phase
  • Wound care
  • Excision and grafting
  • TT
  • Antimicrobials
  • Pain management- Analgesics and sedatives
  • Physical and occupational therapy
  • Nutritional support, GI support
  • Psychosocial care
  • Hydrotherapy: in the form of shower carts, individual showers, and bed baths can be used to clean the wounds.
  • immersion hydrotherapy
  • Because of the high risk of infection and sepsis, thorough decontamination of hydrotherapy equipment and wound care areas are necessary
  • Temperature of the water- 37.8°C (100°F)
  • Should be limited to a 20- to 30-minute
Topical Antibacterial Agents Used for Burn Wounds
AGENT
INDICATION
APPLICATION
Silver sulfadiazine 1% (Silvadene) water  soluble cream

Most bactericidal agent
Minimal penetration of eschar

Apply 1⁄16-inch layer of cream with a sterile glove 1–3 times daily
Mafenide acetate 5% to 10 %(Sulfamylon) hydrophilic-based cream

Effective against gram-negative and gram-positive organisms
Diffuses rapidly through eschar
In 10% strength, it is the agent of choice for electrical burns because of its ability to penetrate thick eschar.
Apply thin layer with sterile glove twice a day and leave open as prescribed. Or if the wound is dressed, change the dressing every 6 hours as prescribed.
Silver nitrate 0.5% aqueous solution

Bacteriostatic and fungicidal
Does not penetrate eschar

Apply solution to gauze dressing and place over wound. Keep the dressing wet but covered with dry gauze and dry blankets to decrease vaporization.
Remoisten every 2 hours, and redress wound twice a day.
Acticoat
Effective against gram-negative and gram-positive organisms and some yeasts and molds
Delivers a uniform, åntimicrobial concentration of silver to the burn Wound

Moisten with sterile water only
(never use normal saline). Apply directly to wound. Cover with absorbent secondary dressing. Remoisten every 3–4 hours with sterile water.

  • Other topical agents are available :
  • Petrolium based ointment
  • Polymycin C
  • Neomycin sulphate
  • Povidone iodine ointment(10%)
  • Gentamicin sulphate
  • Nitrofurazone
  • Dakin's solution
  • Miconazole, Chlortrimazole
  • Bacitracin
  • Suctioning and drainage
  • L A D therapy
  • Minimizing pain by analgesics, narcotics, hypnosis, play therapy, music therapy
  • Wound care and closure: mechanical and surgical debridement
  • Physical and occupational therapy  
  • To maintain optimal joint function
Time of exercise: during and after wound cleansing when the skin is softer and bulky dressing is removed  
Passive and active ROM exercises - on all joints
Neck burns- sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension
Custom fitted splints
Nutritional therapy
  • Goal: to provide adequate calories and protein to promote healing
  • Should begin within the first 1 to 2 days of post bum: high calorie, high protein
  • Daily estimated caloric needs must be regularly calculated by dietician and readjusted as patients condition changes
  • NG tube - with complete liquid diet = for patients on ventilator and unable to consume by mouth
  • Parenteral nutrition
  • Swallowing assessment
  • Ideally weight loss should not be more than 10% of pre-burn weight
  • Weight check on a regular basis


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notes.nursium.com: Burns: Management of Burns- Acute or Intermediate phase
Burns: Management of Burns- Acute or Intermediate phase
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