Regional Burn Unit

The mission of the Regional Burn Center is to enhance wound healing through direct line Nursing and surgical intervention. The goal is to optimize functional outcomes and community re-integration for burn patients through a multi-level delivery system that focuses on state-of-the-art technology and excellence in human service.

We are leaders in the field of burn care by providing:

• the highest level of care through comprehensive and innovative programming;
  
• sensitivity and respect for our patients and their families;
  
• creative solutions to the challenges of the health care environment; and a dynamic and stimulating environment for our professional activities.

The approach to burn management is multidisciplinary team approach. Members of the team are physicians, nurses, physical therapists, occupational therapist, dietitian, pastoral care, health care psychologist, customer service, discharge planner, infection control, respiratory therapy, pharmacy and other health care professionals as needed for each individual patient.

The Burn Team provides dedicated, compassionate, high quality care. The staff is proud of its legacy of improved outcomes for the long term functional results in the burn patient and continues to maintain the standard of excellence which has been the hallmark of Memorial's Burn Center since its inception.

Having a family member or loved one as a patient in The Regional Burn Unit can be a stressful time. To assist you in easing this stress, and addressing some concerns, this webpage has been put together.

• How deep is the burn?
• Understanding the burn injury
• Types of injury
• Wound care
• Dressing types
• Skin grafts
• Nutrition

What Is The Skin?

Epidermis:
A thin cover which is free of blood vessels and is made up of layers of epidermal cells, that vary in thickness over different surfaces of the body. (The epidermis of the soles of the feet is thicker than that of the eyelid.)

Dermis:
The thick inner layer which is composed of many blood vessels, nerve endings, sweat glands and hair follicles (nerve endings responsible for the feeling of pain, temperature and touch are located within the dermis.) The skin provides much more than a tough, flexible surface covering for the body. The skin also protects against infection, prevents loss of body fluid, controls temperature, functions as a sensory organ, produces vitamin D and gives the body identity.

How Deep Is The Burn?

It can sometimes take several days to classify the depth of a burn. Severity is determined by temperature of the source and length of time in contact. Burns are classified as:

1st degree: superficial
2nd degree: partial thickness
3rd degree: full-thickness
4th degree: destruction of fat, muscle & bone.

Superficial Burn:
The outer layer (epidermis) is damaged, Superficial burns usually heal in approximately five to seven days, they are red and painful, have no blisters, peel and leave no scars. A sunburn is classified as a superficial burn.

Partial Thickness Burn:
Skin is blistered into the dermis, but enough cells remain to provide new skin. Partial-thickness burns will usually heal in several weeks, depending on the depth. This burn is painful and scarring can occur.

Full-thickness Burn:
Both layers of the skin are destroyed and the burn involves the subcutaneous area (fatty area).There is no pain because the nerve endings have been destroyed too. Regeneration of new skin is not possible and these areas must be grafted.

Fourth Degree:
Destruction of fat, muscle and bone. This type of burn depends on the temperature and the duration of exposure of the burning agent. It is painless and regeneration is not possible.

1st Degree Burn Epidermis damaged	2nd Degree Burn Epidermis destroyed Dermis damaged	3rd Degree Burn Epidermis destroyed Dermis destroyed Subcutaneous damaged

Understanding The Burn Injury

What is Edema?

Edema is swelling caused by a collection of fluid under the skin tissue. The edema that occurs with burn injuries is the same as the edema you would experience with a severe sprain. However, with a sprain the edema would be localized around the joint sprained. In the burn patient, the size of the wound is generally much larger, causing more edema.

The edema progresses very rapidly for 8 to 12 hours following the burn injury and may last several days. Depending on the burned area, the edema may cause problems for the patient. With facial burns the eyelids probably will swell shut. This can be a very frightening experience for the patient, they will need assurance that after the edema subsides in 48-72 hours they will be able to see.

Treatment for Edema (Swelling):
To reduce the amount of edema normally seen in an injured arm or leg, the extremity is elevated higher than the heart, using pillows or stockinettes.

If the edema increases, threatening impaired circulation, the physician may chose to perform echarotomies or use an enzymatic debrider (to relieve pressure). It is common to observe bloody drainage after either of these procedures. In addition, body fluids may leak through dressings onto the linens. This loss of fluid is the reason for the large amount of IV fluids which is administered during the initial phase of burn care.

What Is Escharotomy?

An Escharotomy is an incision made through the eschar (dead tissue) into the fat layer below to relieve pressure. It is a surgical procedure performed by the physician, with the surgical wound covered by a dressing. Often an escharotomy is necessary in circumferential (burned all the way round) second and third degree burns of the arms, legs and chest. The need for an escharotomy usually occurs within the first 12 to 48 hours following burn injury. The pressure from the edema can cause constriction of the veins, arteries and nerves of the arms and legs, just like a tight tourniquet. In circumferential burns of the chest, the pressure from the edema can prevent the patient from adequately expanding his or her chest wall to breathe.

Types of Injuries

A burn injury can be caused by any of the following:

• Flame: A result of clothing or orther objects igniting
• Scald: Contact with a hot liquid or steam
• Contact: Caused by touching a hot object
• Chemical: When a chemical comes in contact with the skin
• Electrical: When electrical current passes through the body leaving an entrance and exit wound (the visual size of the burn may not reflect the extent or depth of burn.
• Inhalation: An internal injury damaging the respiratory tract caused by breathing excessive smoke or gaseous fumes.

Other skin disorders which may be treated at the burn center.

• Frostbite: A result of tissue freezing from over exposure to cold temperatures
• Toxic Epidermal Necrolysis Syndrome (TENS)
  Sloughing of the skin and mucous membranes caused by an allergic reaction to medication (also referred to as Stevens-Johnson Syndrome)

Wound Care

Wound care is an important part of the healing process. The purpose of wound care is to:

• prevent infection
• remove dead tissue (debridement)
• promote healing

Patients are bathed a minimum of once daily unless they have gone to surgery and the physician orders otherwise. Depending on the patient's condition they may be given a bed bath or placed in a hydrotherapy tub. The burn wounds are gently washed using mild soap and gauze sponges. During the bath, the eschar (dead tissue) that has softened is debrided or removed. This is also an ideal time for exercising since bulky dressings, which hinder movement, have been removed.

After the bath, dressings are reapplied. With the loss of protective skin covering, the patient may become chilled and shake uncontrollaby. This will be most noticeable during and after dressing changes. Blankets are sometimes helpful, but the nurse should be notified before placing a blanket on the patient.
Dressings are specific to each patient and are ordered by the physician. Dressings are applied to burn wounds to prevent infection, promote healing and provide comfort. In spite of the best wound care, infections do occur.

Dressing Types

The most comonly used dressings are:

Ointments:Antibacterial to help prevent infection (examples are SSD, Sulfamylon, Bacitracin)

Solutions: Help to debride the wound, may be antibacterial (examples are normal saline solution, Dakins, hypertonic saline.

Non-adherent Petroleum Gauze: Allows wounds to heal without friction or rubbing (examples are Xeroform or Adaptic.

Synthetic: Temporary covering until wound heals or can be grafted (examples are Biobrane, pigskin, cadaver skin, Integra)

Generally all of the dressing types are covered with dry sterile gauze. Elastic netting is used to keep the dressing in place and allow for movement.

Skin Grafts

Skin grafts, which are a surgical procedure, may be required if the burn is deeper than a partial thickness injury or if the physician feels that the wound would heal too slowly on its own.

The graft, which is a very thin layer of skin, is removed from a donor site using a special instrument called a dermatome. The skin is placed on the clean, debrided wound. The graft is covered with a large protective dressing and left occlusive for several days to promote adherence to the wounded area.

The donor site is the unburned area from which the graft is taken. This area will be quite painful since nerve endings are exposed when the skin is removed. The donor site will usually heal within 10 to 14 days. The most common area used for donor sites are the thighs and buttocks. Ace wraps may have to be worn to prevent swelling in the lower legs.

Nutrition

The body works very hard to try to repair a burn wound. Sometimes weeks and months are neccessary to regenerate new skin and/or to prepare the wound for grafting. The patient remains under constant stress during this time. As the burn wound heals, the body uses an overwhelming amount of energy in the form of calories and proteins, often as much as three to five times the normal amount. These calories and proteins must be provided for the wound to heal. If these calories and proteins are not replaced - infection, malnutrition and weight loss can occur.

Calories and proteins can be replaced by using a feeding tube, special intravenous solutions, high caloric/high protein between-meal milk shakes and meals. Burn patients who are extremely ill usually experience a decreased appetitie and must be continually encouraged to eat. Since calories are monitored closely, it is important to let the nurse know exactly what the patient eats including any foods brought in from home.