1. No category

FAHC Burn Care Manual
Complied by:
Peter Igneri, PA-C, Jennifer Gratton, RN
BURN CARE MANUAL FAHC
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FAHC BURN CARE MANUAL – 2008
Table of Contents
INTRODUCTION ................................................................................ 4
INITIAL ASSESMENT........................................................................ 5
INHALATION INJURY ....................................................................... 8
ESTIMATING TOTAL BODY SURFACE AREA OF BURNS.......... 12
TYPES OF BURNS AND TREATMENTS........................................ 15
DRESSING CHANGES.................................................................... 22
DRESSING TYPES FOR BURNS.................................................... 25
TOPICALS FOR BURN DRESSINGS ............................................. 29
EXCISION AND BURN GRAFTING ................................................ 31
MANAGEMENT OF SPECIFIC BURN AREAS ............................... 35
CHEST...................................................................................................................... 35
AXILLA.................................................................................................................... 35
NECK AND BREAST.............................................................................................. 36
LOWER EXTREMITIES ......................................................................................... 36
UPPER EXTREMITIES........................................................................................... 37
HANDS..................................................................................................................... 37
BACK ....................................................................................................................... 38
PHASES OF GRAFT MATURATION........................................................................ 39
LONG TERM COMPLICATIONS.............................................................................. 41
BURN NUTRITION........................................................................... 44
BURN NUTRITION - PEDIATRIC .................................................... 50
BURN REHABILITATION................................................................ 53
BURN CARE MANUAL FAHC
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HYPOTHERMIA AND FROSTBITE................................................. 58
Frostbite protocol .......................................................................................................... 60
PEDIATRIC BURNS: SPECIAL CONSIDERATIONS ..................... 61
PSYCHOSOCIAL ASPECTS OF BURNS ....................................... 64
BURN CARE REMINDERS ............................................................. 65
WEBSITE REFERENCES................................................................ 67
BURN (Dressing change) CART INFORMATION ......................... 68
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INTRODUCTION
This burn care document was developed by the burn committee as a
resource for Fletcher Allen staff that may have questions in regards to
caring for the burn patient.
Although there are advances in burn treatments most of the
documents in this binder remain the standard of care for the patient.
As new treatment develops the manual can easily be updated.
Thanks to all of the people that researched information for the manual
for all there time and effort.
Fletcher Allen Burn Committee
Jennifer Gratton, RN Trauma Program Supervisor
Peter Igneri, PA Trauma Service
Lori Camp, RN Trauma Case Manager
Jess Langer, RN Care Coordinator Baird 6
Pam Kupiec, RN Baird 6
Marie Zebertavage, RN Baird 6
Tracey Wagner, RN Baird 5
Carole Richards, RN Baird 5
Gail Tuscany, RN SICU
Patrick Delaney, RN SICU
Patty Crease, RN SICU
Gil Helmken, RN ED
Ray Scollins, RN FACT
Kristen Brewster Occupational Therapy
Barb Blokland Occupational Therapy
Karyann Bombardier Physical Therapy
Julie Jacob, SW Trauma Social Worker
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Burn Care
INITIAL ASSESSMENT
Primary Survey
A – Airway.
• Secure the airway first.
• Get history as much as reasonably possible before intubation
• Soot or singed nasal hairs?
B – Breathing;
• High flow Oxygen for all.
• Escharotomy? - Monitor chest wall excursion in presence of FT torso
burns
• Listen: verify breath sounds
• Assess rate & depth
C – Circulation
• Monitor BP,
• pulse rate,
• skin color
• Establish IV access,
• Warm IV fluids
• Monitor peripheral pulses in circumferential burns.
D - Disability;
• Associated Injuries?
• CO poisoning?
• Substance abuse?
• Hypoxia?
• Pre-existing medical condition
E – Exposure;
• Remove all clothing and jewelry
• Ensure warm environment
• Clean DRY blankets
• It is OK to use water to stop the burning process and clean but not at the
expense of reducing body core temperature.
Secondary survey
Repeat Primary
Complete head to toe evaluation
Start after resuscitation fully established
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Complete the HPI
• What type of burn (flame, chemical, scald)
• Duration of exposure
• What time did burn occur?
• What treatment already provided.(chemical brushed off, water to cool, etc)
• Did burn occur in house fire/enclosed space (think inhalation injury)
Order labs and x rays
• CBC, BUN, Cr, Lytes
• Carboxyhemoglobin
• CXR
• Blood gas
• Insert Foley
• EKG (especially in electrical injury)
Special considerations;
• Abuse patterns
o Children, elderly
• Concomitant trauma
o C-spine precautions
o Trauma protocols if trauma is majority of injuries
Determine TBSA
• Use Lund Browder chart.
• Can start with patients palm = 1% of patients BSA
• A good online program is sagediagram.com. Need patient weight and
height and age for this program. Can print out a graphic with parkland
calculations.
Initiate resuscitation strategy – DO NOT need on <15% TBSA
• Parkland formula
o 2-4 ml RL X kg X % BSA burn
o ½ in 1st 8 hrs
o ¼ in 2nd 8 hrs
o ¼ in 3rd 8 hrs
• Pediatric parkland
o 2-4 ml RL X kg X % BSA burn
o ½ in 1st 8 hrs
o ¼ in 2nd 8 hrs
o ¼ in 3rd 8 hrs
o add maintenance fluid – use D5LR
ƒ 100cc/kg for 10 kg of weight
ƒ 50 cc/kg next 10 kg of weight
ƒ 20cc/kg remaining 10 kg after
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Pediatric calculation example
23 Kg child with 20% deep burn
♦ Resuscitation (Ringer’s Lactate)
3 ml X 23 Kg X 20% Burn = 1380 mls
½ in 1st 8 hrs post burn = 86 cc/hr
♦ Maintenance (D5LR)
• 1st 10 Kg: 100 cc/kg/24hr = 1,000 cc/24 hr
• 2nd 10 Kg: 50 cc/kg/24hr = 500 cc/24 hr
• Remaining 3 Kg: 20cc/kg/24hr = 60 cc/24 hr
1560 cc/24 hr = 65cc/hr
Cleaning & Debridement –
• Whenever possible, clean using mixture of Hibiclens and sterile water (not
saline – it stings more when mixed with Hibiclens).
• If picking patient up at OSH, remove wet dressings and place bacitracin
and fluffs or Exu-Dry for transport.
• If transporting out to MGH or other larger Burn center, contact them and
find out what they like for dressings on transferred patients. (i.e. MGH
typically wants a dry sterile dressing)
• Assemble team to view at same time to avoid time consuming dressing
removal and reapplication.
• Take picture(s) if possible – print color pictures for chart.
• Involve resident physicians to teach when possible.
• First cleaning should take place in the ED if possible. Set a plan for the
next cleaning/shower time and let other team members know.
• Use reverse isolation precautions to clean and débride when
• TBSA>15%
• Associated inhalation injury
• Immunocompromised patient.
Dressings/Supplies:
• There is a burn care cart in the ED that requires a key from PIXIS system.
Keep track of supplies in order to replace on cart ASAP.
• The SICU does not stock burn dressings. If needed for the SICU order
burn cart through distribution/transport tracking.
• Please ensure IBM card used to deal with cost center issues when getting
supplies from another unit.
• Mepilex Ag dressing is available only in CSR as of May 2008. It may be
stocked in the patient floors in the future.
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INHALATION INJURY
The three injury processes, resulting from smoke exposure, are presented in the
order in which peak symptoms occur.
• Carbon Monoxide Toxicity- peak symptoms immediate
• Upper Airway Injury with Potential Obstruction – peak
symptoms can be delayed for an hour or more
• Lower Airway Injury with Impaired Gas Exchange- peak
symptoms can be delayed for hours
Carbon Monoxide Toxicity
Pathophysiology:
Carbon Monoxide binds to the hemoglobin molecule displacing oxygen thereby
decreasing the oxygen delivered to tissue. The affinity of CO to hemoglobin is
much higher than O2.
Risk Factors
• Any exposure to smoke
• Any exposure to fumes
Diagnosis
• Pulse oximeter may be completely normal value as it only measures O2 level.
• A high index of suspicion in any fire victim with a history of smoke exposure
• A carboxyhemoglobin level exceeding 10% total (Morbidity is related to
peak level at scene not the first value obtained)
• Unexplained metabolic acidosis
Hgb Level
Carbon Monoxide
Intoxication
CO High Symptoms
0-5
Normal Value
15-20
Headache, Confusion
20-40
Disorientation, fatigue,
nausea, visual changes
40-60
Hallucination,
combativeness, coma,
shock, shock state
60 or
above
Cardiopulmonary arrest,
Death
*CO Hgb - carboxyhemoglobin
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Table 2: Treatment of Carbon Monoxide and Cyanide Toxicity
Carbon Monoxide
Awake
High flow by mask
oxygen (Fi02 100%)
until
carboxyhemoglobin
< 10%
Cyanide
Obtunded
Metabolic Acidosis
Intubate
Cardiovascular support
100% oxygen via
positive pressure
ventilation
Sodium nitrite followed by sodium
thiosulfate if there is a high
likelihood of toxicity (unexplained
metabolic acidosis)
Hyperbaria used if
patient not
responding to 100%
oxygen (specific
indications remain
undefined)
Upper Airway Injury:
Pathophysiology:
Direct heat injury caused by the inhalation of air heated to a temperature (150° C
or higher) ordinarily results in burns to the face, oropharynx, and upper airway
(above the vocal cords). Even superheated air is rapidly cooled before reaching
the lower respiratory tract because of the tremendous heat-exchanging efficiency
of the oropharynx and nasopharynx.
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Pathophysiology of Airway Injury:
The initial response to smoke is usually that caused by intense airways irritation,
and airways edema producing increased airways resistance. The late response,
typically seen 2 to 5 days after the insult, is the result of the initial mucosal injury
leading to mucosal slough, increased secretions, intense airways inflammation
and impaired immune function.
The Lung Injury: Lower airway
The degree of initial and late injury will, in large part, be related to the status of
the pre-injured lung. A lung with any element of reactive airway disease or
chronic changes from smoke, for example, will likely react more severely to a
smoke exposure than a healthy lung. In addition, the inflammatory response
caused by the injury will lead to much of the subsequent damage. Oxidants in
smoke and those released by inflammatory cells play a critical role in the airways
BURN CARE MANUAL FAHC
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injury. A decrease in lung anti-oxidants is also seen further increasing the
degree of injury.
The mechanism of the airway and parenchymal injury is complex. The cell toxic
agents, present on the particulates lead to a number of pathologic events. First,
there is direct mucosal injury, loss of ciliary activity with subsequent impairment
of particulate and mucous clearance and later bacterial clearance. Second,
there is a marked, early increase in bronchial blood flow, as well as increased
bronchial vessel permeability, leading to submucosal edema and vascularengorgement narrowing of the airway lumen. Third, there is tissue destruction
due to the above response, as well as a secondary inflammatory response. The
result is a slough of mucosa in both large and small airways, and a marked
increase in mucous production.
Lower Airway Injury:
Closely resembles the same signs and symptoms as upper airway, especially
during the acute phase of burns.
Signs and Symptoms
•
•
•
•
•
•
•
•
Inhalation Burns
Burns of face, mouth or neck
Singed nasal /facial hair
Red & dry mucosa
Edema of tongue or pharynx
Chest tightness
Hoarseness, wheezing, stridor
Cough or dyspnea
Profuse secretions, sooty sputum
30
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ESTIMATING TOTAL BODY SURFACE AREA OF BURNS
Total Body Surface area, TBSA, for burns is calculated based on the partial and
full thickness burns (not superficial, first degree burns)
It is important to make an initial calculation early on, and follow up with updated
estimates in the following days to see the progression/regression of the burns.
All Admitted patients to FAHC should have a Lund Browder or Sage diagram
placed in the front of the clinical records of the chart.
Lund Browder –
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It takes into account the age of the patient as it relates to the TBSA.
SAGE diagram
Another tool to use is the Sage Diagram. This is available via the internet at:
www.sagediagram.com
This is a free service which permits the user to draw in the areas burned on a
diagram, and based on the patient’s height and weight will provide an estimated
total body surface area of burns. This diagram can be printed for charting.
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Following the RULE OF NINE’S
Adults: Each arm is 9%, each leg is 18%, the front of the torso is 18%, the Back
is 18%, the head and neck are 9%, and the perineum is 1%
Children: Modified due to larger head proportionately: Each arm is 9%, each leg
is 14%, Front and back are 18% each, and the Head is 18%
Estimating the size of the Burn as a % of the Total Body Surface (TBSA)
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TYPES OF BURNS AND TREATMENTS
First Degree Burns- superficial burns
A first degree burn is confined exclusively to the outer surface and is not
considered a significant burn. No skin barrier functions are altered. The
most common form is sunburn which heals by itself in less than a week
without a scar.
Treatment
Topical antimicrobial (Bacitracin) applied several times a day
Second Degree Burns- partial thickness burns
Second degree burns cause damage to the epidermis and portions of the
dermis. Since it does not extend through both layers, it is termed partial
thickness. There are a number of depths of a second degree or partial
thickness burn which are used to characterize the burn.
Superficial Second Degree
Involves the entire epidermis and no more than the upper third of the
dermis is heat destroyed. Rapid healing occurs in 1-2 weeks, because of
the large amount of remaining skin and good blood supply. Scar is
uncommon. Initial pain is the MOST SEVERE of any burn, as the nerve
endings of the skin are exposed to the air.
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Appearance
The micro vessels perfusing this area are injured resulting in the
leakage of large amounts of plasma, which in turn lifts off the heatdestroyed epidermis, causing blisters to form. The blisters often increase
in size even after the burn. A light pink, wet appearing very painful wound
is seen as the blisters are disrupted. ** Frequently, the epidermis does not
lift off the dermis for 12 to 24 hours and what initially appears to be first
degree is actually a second degree burn.
Treatment
Debridement of affected skin to expose underlying wound. Debride
blisters that are limiting joint movement.
Clean wound and apply antimicrobial ointment such as bacitracin.
Excellent alternative is the use of skin substitute which seals the wound
and decrease pain. Below is an example of Biobrane application-usually
put on in the Emergency Department setting.
Must débride blisters prior to placing to allow firm adhesion
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Also can apply closed dressing of gauze for absorbency and wrap.
This will need to be changed daily.
Healing
This type of burn heals in 10-12 days without scarring. There is a low
risk of infection.
Mid-Second degree-Mid partial thickness burn
In this type of burn, destruction to about half the dermis occurs. Healing is
slower due to the fact that there is less remaining dermis and less of a
blood supply. Pain can be severe but is usually less intense than the
superficial due in part by nerves that are destroyed.
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Appearance
The burn surface may have blisters but is redder and less wet.
Treatment
Treatment is typically Silvadene cream and occlusive dressing with a
closed dressing technique. A temporary skin substitute is also a treatment
of choice.
Healing
This type of burn usually heals in 2 to 4 weeks. The longer the
healing time, the more chance of scarring.
Deep Second Degree-Deep partial thickness
In this type of burn most of the skin is destroyed except a small amount of
remaining dermis. The wound looks white or charred indicating dead
tissue. Blood flow is compromised and a layer of dead dermis or eschar
adheres to the wound surface. Pain is much less as the nerves are actually
destroyed by the heat. Usually, it is difficult to distinguish a deep dermal
burn from a full thickness burn by visualization. The presence of sensation
to touch usually indicates the burn is a deep partial injury.
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Appearance
The wound surface may be dry and red in appearance with white
areas in the deeper parts. There is marked decrease in blood flow making
the wound very prone to conversion to a deeper injury and to infection.
Direct contact with flames is a common cause. The appearance of the deep
dermal burn changes dramatically over the next several days after burn as
the area of dermal necrosis along with surface coagulated protein turns the
wound a white to yellow color. This resembles the third degree burn and
differentiation sometimes is difficult. The presence of some pain can assist
in diagnosis because the pain is usually absent in full thickness injury.
Treatment
Wash with antimicrobial soap and water. Apply silvadene closed
dressing. Often grafting is needed to speed healing. Monitor for infection.
Often converts to full thickness injury.
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Note how fingers are wrapped separately to maintain motion
Healing
This type of burn may heal in 2-3 months. If it heals scarring is
usually severe.
Full thickness burns
Both layers of skin are completely destroyed leaving no cells to heal. Any
significant burn will require skin grafting. Small burns will heal with scar.
Entire destruction of the epidermis and dermis, leaving no residual
epidermal cells to repopulate.
Appearance
A characteristic initial appearance of the avascular burn tissue is a
waxy white color. If the burn produces char or extends into fat as with
prolonged contact with a flame source, a leathery brown appearance can
be seen along with surface coagulation veins. The burn wound is painless
and has a coarse non-pliable texture to touch.
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Treatment
Wash with antimicrobial soap and water. Apply Silvadene cream with a
closed dressing. Grafting is treatment of choice. High risk for infection.
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DRESSING CHANGES
FULL THICKNESS AND DEEP PARTIAL THICKNESS (PRE-GRAFT)
For the Bedside nurse/provider:
1) Gather necessary supplies (order burn cart via transport tracking)
2) Ensure adequate quantities of burn creams.
3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Kerlix,
clean white gloves, and other items
4) Have adequate pain medicine available
5) Connect with PT/OT, BST to establish time of burn care
PREPARATION:
1) Gather all materials prior to starting burn care
2) Have adequate amounts of gowns, hats, masks, and sterile gloves for all staff
participating in care
3) Remove dressings, exposing a minimal amount of body surface area to prevent
hypothermia
4) In sterile fashion, cleanse area with equal amounts of Hibiclens and sterile saline,
using lap sponges
5) Débride areas of loose skin and eschar with sterile scissors
6) Allow to air dry
7) Apply ordered creams to affected areas, usually Silvadene to torso and limbs,
Bacitracin to face, and Sulfamylon to cartilaginous area
8) Cover wounds with Exu-Dry, contain Exu-Dry with Kerlix wraps if needed
SUPERFICIAL (FIRST DEGREE) AND HEALED DONOR SITES
For the Bedside nurse/provider:
1) Gather necessary supplies (order burn cart via transport tracking)
2) Ensure adequate quantities of burn creams
3) Have adequate dressing supplies, including Exu-Dry, gauze, Fluffs, Xeroform, Kerlix,
clean white gloves, and other items
4) Have adequate pain medicine available
5) Connect with PT/OT, BST to establish time of burn care
Procedure:
1) Wash and/or have patient help wash all affected areas with anti-bacterial soap and
water
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2) Pat dry with clean cloth
3) Apply Eucerin Cream to areas, remembering that with application, “Some is good, More
is better”
4) Cover, if ordered, with loose dressing, or with clean white shirt if on torso, or clean
white gloves (turned inside-out) if on hands
5) Reinforce dressings, and reapply creams as ordered and PRN to keep skin well-coated
NEWLY GRAFTED BURNS AND DONOR SITES
For the Bedside nurse/provider:
1) Gather necessary supplies (order burn cart via transport tracking)
2) Ensure adequate quantities of burn creams
3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Kerlix,
clean white gloves, and other items
4) Have adequate pain medicine available
5) Connect with PT/OT, BST to establish time of burn care
PROCEDURE:
1) Have adequate amounts of gowns, hats, masks, and sterile gloves for all staff
involved with procedure
2) Maintain integrity of newly grafted burn sites for 5 days, or unless directed otherwise
by house staff
3) Minimize areas uncovered during burn care to maintain euthermia
4) Remove dressings from donor sites to Xeroform- remove via sterile scissors only
the areas peeling back or loose
5) Cleanse with equal amounts of Hibiclens and Sterile Saline
6) Allow to air dry
7) Apply generous amounts of Bacitracin over Xeroform, remembering that with
creams, “Some is good, More is better”
8) Cover with Telfa and Kerlix, making sure distal circulation is not constricted
9) ** Newly grafted burn dressings must be removed initially by house staff, to assess
successful take of grafted skin**
DRESSING CHANGES
PARTIAL THICKNESS AND DONOR SITES
For the Bedside nurse/provider:
1) Gather necessary supplies (order cart via transport tracking)
2) Ensure adequate quantities of burn creams
3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Kerlix,
clean white gloves, and other items
4) Have adequate pain medicine available
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5) Connect with PT/OT, BST to establish time of burn care
PROCEDURE:
1) Have staff wear gown, gloves, and mask for burn isolation
2) Cleanse wounds with sterile Hibiclens and Saline (mixed in equal amounts), washing
with lap sponges if available
3) Note: gentle scrubbing will help with light debriding of partial thickness burns, and
remove previous creams
4) Clip any loose or pealing Xeroform from donor sites, using sterile scissors
5) Allow to air dry
6) Cover areas affected with Bacitracin, unless otherwise directed. Remember: When
applying creams, “Some is good, More is better”
7) Apply Exu-Dry dressing over partial thickness burns, Telfa pads covered by Kerlix, or
dressed as ordered ** Be sure dressings are not constrictive to peripheral/distal
circulation
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DRESSING TYPES FOR BURNS
EXU-DRY- non-adherent dressing made up
of multiple layers. It is designed to conform readily and comfortably to contoured
areas. It is highly absorbent and has an anti shear layer. It is compatible with
topical agents. Mainly used with first and second degree burns and after grafting.
It comes in gloves and jackets and pants also.
FLUFFS-these are woven gauze dressings used over third
degree burns to assist in debriding prior to grafting. These can
be used out of package or a Kerlix can be opened all the way
up to use as a fluff. It is often used as a padding layer to
protect grafts postop and to apply soft but constant pressure
onto the grafts to facilitate imbibition.
CONFORM - this is slightly elastic cotton roll gauze dressing. It
is good for use on fingers and anywhere that mobility is
important as it flexes easily. It comes in 1 inch and up sizes.
KERLEX- this is used to wrap burns and
assist in keeping underlying dressings in
place. Often used over Exu-Dry to keep in
place.
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Coban – this is an elastic self adherent dressing that is used to
help with reduction in the amount of swelling in an extremity burn.
It is used over and in conjunction with other dressings mentioned
herein.
ACE - these commonly found elastic wraps are
used over dressings to help with swelling and
sometimes just used to keep materials in place.
MEPITEL-Mepitel is a porous, semi-transparent,
low-adherent wound contact layer, consisting of a flexible polyamide net coated
with soft silicone. The silicone coating is slightly tacky, which facilitates the
application and retention of the dressing to the peri-wound area. This gentle
adhesion also tends to prevent maceration by inhibiting the lateral movement of
exudate from the wound on to the surrounding skin. The nature of the bond that
forms between Mepitel and the skin surface is such that the dressing can be
removed with minimum pain and without damaging delicate new tissue. Mepitel
is not absorbent, but contains apertures or pores approximately 1mm in diameter
that allows the passage of exudate into a secondary absorbent dressing.
Depending on the nature and condition of the wound, Mepitel may be left in place
for extended periods, up to 7-10 days in some instances, but the outer absorbent
layer should be changed as frequently as required. When Mepitel is used for the
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fixation of skin grafts and protection of blisters, it is recommended that the
dressing should not be changed before the fifth day post-application. It can be
used under a wound vac. It can be removed and cleaned with mild soap and
water and reused. Washing will restore the stickiness to the material.
XEROFORM - Xeroform Petrolatum Gauze is a sterile dressing composed of 3%
Bismuth tribromophenate in a petrolatum blend on fine mesh gauze. The
Xeroform gauze patch is a medicating and deodorizing, occlusive and nonadhering dressing packaged in sterile convenient peel-open, tamper-proof
packages. Xeroform has a bacteriostatic action.
Its property is 3% Bismuth Tribromophenate in a special petrolatum blend on fine
mesh gauze. It is non-adherent and conforms to body contours.
We often use Xeroform to cover an open wound in
the days right after a graft is taken down and the
staples taken out, and occasionally over a donor
site. When used as a donor site covering, do not
peel off! Allow neoepitheliazation to ‘push’ the
dressing off. Trim the edges that are not longer
adherent. Sometimes bacitracin is used to add
another layer of moisture and no stick to the fine
mesh gauze dressing.
MEPILEX AG-The new Mepilex Ag is a novel antimicrobial dressing since it
combines silver with Safetac soft silicone technology. It targets bacteria and
protects the skin. This dressing will release silver for up to 7 days. It may be
lifted and adjusted without losing its adherent properties. It also can be cut to size
and is easy to apply. . In order for the silver to activate, there must be active
serous discharge from the wound. It will not provide antimicrobial protection
without being moist.
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Tubigrip – stretching cotton dressing used to apply pressure to swollen area or
sometimes just used to keep dressing in place. Can make a shirt out of larger
sizes.
White cotton Gloves – these are simply white cotton gloves used as a dressing.
It allows for increased mobility while still protecting the burn. Hands and glove
are coated in appropriate topical agent (usually bacitracin). These gloves can be
cleaned and dried and used again. Turn gloves inside out so seems are on the
outside (more comfortable).
BandNet – (Spandage)
Tubular mesh netting type dressing that allows contact
layers to stay in proximity to the wound. Sometimes used
on the OR in order to apply pressure to the dressing and
keep graft in place. When used over a graft will be stapled
in place.
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TOPICALS FOR BURN DRESSINGS
FOR ALL TOPICALS: Some is good, more is better! Too much can cause
reactions. Thin coat of topical directly on burn and then more topical
applied to the dressing material prior to placing over burn is best.
SILVADENE (Silver Sulfadiazine): Initial cream for suspected partial and fullthickness burns (2nd and 3rd degree).
Action: Contains Silver Sulfadiazine in micronized form which has broad
microbial activity. It is bactericidal against many gram-negative and gram-positive
bacteria as well as being effective against yeast. This is also used to help partial
and deep partial-thickness burns to slough off eschar.
The patient may have pain, burning and itching at the site of application.
Precautions: Use cautiously if patient has a sulfa allergy.
Because sulfonamide therapy is known to increase the possibility of kernicterus,
Silvadene Cream 1% should not be used on pregnant women approaching or at
term, on premature infants, or on newborn infants during the first 2 months of life.
SULFAMYLON (mafenide): Used for its anti-infective and antimicrobial agents,
primarily over cartilage, such as ears in 2 deep second and third degree burns.
Action: Sulfamylon Cream, applied topically, produces a marked reduction in the
bacterial population present in the avascular tissues of second- and third-degree
burns. Reduction in bacterial growth after application of Sulfamylon Cream has
also been reported to permit spontaneous healing of deep partial-thickness
burns, and thus prevent conversion of burn wounds from partial-thickness to fullthickness. It should be noted, however, that delayed eschar separation has
occurred in some cases. Frequently associated with increased pain at the
application site.
Precautions: Sulfamylon and its metabolite, inhibit carbonic anhydrase, which
may result in metabolic acidosis, usually compensated by hyperventilation. In the
presence of impaired renal function, high blood levels of Sulfamylon and its
metabolite may exaggerate the carbonic anhydrase inhibition. Therefore, close
monitoring of acid-base balance is necessary, particularly in patients with
extensive second-degree or partial-thickness burns and in those with pulmonary
or renal dysfunction. Some burn patients treated with Sulfamylon Cream have
also been reported to manifest an unexplained syndrome of marked
hyperventilation with resulting respiratory alkalosis (slightly alkaline blood pH, low
arterial pCO2, and decreased total CO2); change in arterial pO2 is variable. The
etiology and significance of these findings are unknown.
Mafenide acetate cream should be used with caution in burn patients with acute
renal failure.
Sulfamylon Cream should be administered with caution to patients with history of
hypersensitivity to mafenide. It is not known whether there is cross sensitivity to
other sulfonamides.
BURN CARE MANUAL FAHC
29
Fungal colonization in and below eschar may occur concomitantly with reduction
of bacterial growth in the burn wound. However, fungal dissemination through the
infected burn wound is rare.
SILVER NITRATE: Used in liquid form as a wet dressing over partial and full
thickness burns, for patients with sulfa allergies. Requires frequent re-application
to keep area moist.
Action: Silver Nitrate is a topical solution agent with bacteriostatic properties
against staph aureus, E. Coli, and Ps. Aeruginosa. It is most effective with the
wound is clean and débrided of all dead tissue.
Precautions: May cause hyponatremia, monitor electrolytes closely.
Will cause discoloration of skin, clothes and equipment.
BACITRACIN: Used with partial thickness burns, with grafted areas initially after
dressing removed, with donor sites until nearly healed, and with facial burns.
Action: Bacitracin is produced by a strain of the bacterial species Bacillus
subtilis. It is widely used for topical therapy such as for skin and eye infections; it
is effective against gram-positive bacteria, including strains of staphylococcus.
Precautions: May cause burning, redness or a rash at which time the ointment
should be stopped.
EUCERIN: Used for first degree (superficial) burns and for healing partial
thickness burns, grafted burns, and donor sites to keep area moist.
Action: Moisturizing lotion
BURN CARE MANUAL FAHC
30
EXCISION AND BURN GRAFTING
A skin graft is surgical procedure in which a piece of skin from one area of the
patient's body is transplanted to another. Skin from another person or animal
may be used as temporary cover for large burn areas in order to decrease fluid
loss. The skin is taken from a ‘donor site’, which has healthy skin and implanted
at the damaged ‘recipient site’. Skin graft and flaps are more serious than other
scar revision surgeries such as dermabrasion. They are usually performed in a
hospital under general anesthesia. The treated area depending on the size of the
area and severity of the injury will determine the amount of time needed for
healing. This time may be 6 weeks or a few months. Within 36 hours of the
surgery new blood vessels will begin to grow from the recipient area into the
transplanted skin. Most grafts are successful, but some may require additional
surgery if they do not heal properly.
There are several types of skin grafts: pinch, split-thickness, full-thickness,
and pedicle grafts.
• Pinch grafts - Quarter inch pieces of skin are placed on the injured site.
These small pieces of skin will then grow to cover injured sites. These will
grow even in areas of poor blood supply and resist infection.
•
Split-thickness grafts - consists of sheets of superficial and some deep
layers of skin. The grafts removed from the donor sites may be up to 4
inches wide and 10 to 12 inches long. The grafts are then placed at the
recipient site. Once the graft is in place, the area may be covered with a
compression dressing or the area maybe left exposed. Split-thickness
grafts are used for non-weight-bearing parts of the body.
•
Full-thickness grafts - are used for weight-bearing portions of the body
and friction prone areas such as, feet and joints. A full-thickness graft
contains all of the layers of the skin including blood vessels. The blood
vessels will begin growing from the recipient area into the transplanted
skin within 36 hours.
•
Pedicle grafts - with a pedicle graft a portion of the skin used from the
donor site will remain attached to the donor area and the remainder is
attached to the recipient site. The blood supply remains intact at the donor
location and is not cut loose until the new blood supply has completely
developed. This procedure is more likely to be used for hands, face or
neck areas of the body.
The success of a skin graft can be determined within 72 hours of the surgery. If a
graft survives the first 72 hours without an infection or trauma the body, in most
cases, will not reject the graft. Before the surgery, the recipient and donor sites
must be free of infection and have a stable blood supply. Following the procedure
moving and stretching the recipient site must be avoided. Dressings need to be
sterile and antibiotics may be prescribed to avoid infection.
BURN CARE MANUAL FAHC
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EXCISION
There are two types of excisions when skin grafting, fascial and tangential.
• Fascial: burn eschar is excised down to muscle fascia. Good graft take,
decreased bleeding, fast. Cosmetic and functional results worse than with
tangential excision. Perform where burn depth is deep into subcutaneous
tissue, person may not tolerate blood loss, or where reduced blood loss
and stress outweigh cosmetic and functional advantages of tangential
excision
•
Tangential: burn débrided to briskly bleeding dermis or glistening fat.
Bleeding and operative time increased. Improved functional and cosmetic
results. Blood loss much higher.
BURN CARE MANUAL FAHC
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EXCISION
PROS
Tangential
Improved function
High blood loss
Improved cosmesis Need more skin
Takes longer
Risk over/under excision
End points hard to define
Rapid
Cosmetic defect
Defined endpoints Risk of nerve injury
Wide-mesh grafts
Risk of joint exposure
Good graft take
Distal edema
Skin substitutes
Fascial
CONS
FASCIAL EXCISION
TANGENTIAL EXCISON
Good, brisk bleeding used at guide to depth of excision
Early excision and grafting (2-5 days post injury) is associated with improved
outcomes. After one week there is and increased dermal blood flow and
BURN CARE MANUAL FAHC
33
granulation is forming under eschar. This results in an increased blood loss with
excision.
It is best to only excise up to 18-25%TBSA in the first operation and never more
than 18% in a single operation after that.
Monitor the patient’s temperature closely and if unable to maintain normothermia
the operation should be stopped.
Post operatively patients may experience periods of hypotension and decreased
urine output. This is due to vasodilatation, re-warming and loss of the tourniquet
effect after the constricting eschar is removed.
EXCISION AND GRAFTING IMPORTANT POINTS:
-harder than you think
-requires planning ahead to figure out what you want to accomplish and how you
are going to accomplish it
-what are you going to use for back up skin (cadaver, Biobrane, Integra)
-what type of excision
-what type of graft
-what is the best position for the patient
-make sure you have enough help before you go the to OR
-If burn requires splinting, make sure to coordinate with therapists in advance
Surgical Approach Based on Burn Size-Must Prioritize
1. Life
2. Limb
3. Looks
BURN CARE MANUAL FAHC
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MANAGEMENT OF SPECIFIC BURN AREAS
CHEST
Management Based on Specific Burned
Area-Chest
• Chest/abdomen high
priority in large and
moderate sized burn.
• If FT burn excise to
fascia (spare
umbilicus and
nipples), 3:1 graft.
• Skirt axilla, do not
excise to fascia.
AXILLA
Management Based on Specific Burned
Area-Axilla
• Skirt axilla, do not
excise to fascia.
• Need to excise and
graft chest or shoulder
first.
• Wait until
chest/shoulder healed
to tangentially excise
axilla; allows anchoring
of grafts.
• Axilla takes high priority
in smaller burns and
should be grafted after
hands.
BURN CARE MANUAL FAHC
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NECK AND BREAST
Management Based on Specific Burned
Area-Neck & Breast
• Neck low priority in
massive burns, but a
high priority in small
burns.
• Thick sheet grafts
(20/1000s in) or 1:1 mesh
preferred for neck.
• Breast burns in younger
women tangentially
excised. In elderly
consider mastectomy.
LOWER EXTREMITIES
Management Based on Specific Burned
Area-Lower Extremities
• 2nd priority after chest in
massive burns. Excise
to fascia if full thickness.
• In moderate burns
excise FT leg burns to
fascia if there are hand,
neck, or face burns that
require lots of skin.
• For small burns prefer
tangential excision with
sheet grafts over joints.
BURN CARE MANUAL FAHC
36
UPPER EXTREMITIES
Management Based on Specific Burned
Area-Upper Extremities
• Lower priority to excise to
fascia in massive burns
(9%TBSA). Cover with
3:1 except 1.5:1 over
elbow, wrist, hands.
• Small burns tangentially
excise and use 1.5:1 over
arm and sheet grafts over
elbow and hands.
HANDS
Management Based on Specific Burned
Area- Hands
• Lower priority in massive
burns. Need a lot of skin .
May need to pare down
eschar and wait until
granulation forms to graft.
• Small burns hands a
priority. Tangentially
excise and use 1:1or
sheet graft.
BURN CARE MANUAL FAHC
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BACK
Management Based on Specific Burned
Area- Back
• Very thick skin so will
often heal. Delay in
massive burns unless
absolutely sure is FT,
then excise to fascia,
graft 3:1.
• Smaller burns: wait to do
back until priority areas
closed.
ƒ
GRAFTING IMPORTANT POINTS
Sheet grafts or unopened 1:1 meshed graft should be used for functional
areas such as hands, neck or elbows
ƒ
Secure grafts with clips, staples, or absorbable sutures. Remember the
clips and staples have to come out so use these judiciously
ƒ
Immobilize seams
ƒ
Wound-vacs are often used to keep graft in place
ƒ
Cover grafts with Xeroform or Adaptic and staple in place
ƒ
Use large bulky absorbent dressing to protect grafts
ƒ
Take down occurs post operative day 5
ƒ
Use Eucerin once grafts healed to keep from drying out
ƒ
DONOR SITES IMPORTANT POINTS
Bleed vigorously, use thrombin and epinephrine for immediate hemostasis
ƒ
Cover with Xeroform, will separate from donor site when healed
ƒ
Healing occurs in 10-14 days
ƒ
Deep donor sites (>0.016 inch) should be grated with a thin (0.005 inch)
graft to speed healing and minimize scarring
ƒ
Use Eucerin over healed donor sites to keep moist
BURN CARE MANUAL FAHC
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PHASES OF GRAFT MATURATION
Three phases:
1. Adherence: fibrin bonds between graft and excised bed form
immediately. Fibrovascular ingrowth by 3 days.
2. Imbibition: Cell swelling in first 48 hours, may nourish graft.
3. Revascularization: vascular connections form in 4-7 days, lymphatic
connections one week
5 DAYS POST GRAFTING
BURN CARE MANUAL FAHC
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14 DAYS POST GRAFTING
21 DAYS POST GRAFTING
BURN CARE MANUAL FAHC
40
LONG TERM COMPLICATIONS
HYPERTROPHIC SCARRING
• Hypertrophic scar
more common after
spontaneous closure
of DPT burns or
healing of widely
meshed grafts.
• Deep donor sites.
HYPERTROPHIC SCARRING
• Compression
garments can help
control hypertrophic
scarring.
• Restrict capillary
blood flow.
• Garments worn 12-18
months for 23 hours a
day, 7 days a week.
BURN CARE MANUAL FAHC
41
CONTRACTURES
• Grafts and
spontaneously
healing burns may
develop contractures.
• Splinting, aggressive
OT/PT, and early
grafting may prevent
contractures.
HETERTROPHIC
OSSIFICATION
• Bone deposition outside of bone. X-rays
show calcifications in soft tissues.
• ? Causes
• Often occurs in joints injured by burns or in
grafted or healed burns.
• May show up months-years after injury.
• Symptoms pain, limitation of mobility.
• Treatment PT, analgesics, surgery.
BURN CARE MANUAL FAHC
42
Marjolin’s Ucer
• Squamous cell
carcinoma that can
occur in an area of
healed or grafted
burns.
• May develop decades
after the original
injury.
BURN CARE MANUAL FAHC
43
BURN NUTRITION
Characteristics:
Nutrition needs are altered in patients with burns. Energy (calorie) and protein
needs are elevated and remain high after a burn and during subsequent
treatment. If other injuries accompany the burn, the additional injuries also
increases calorie needs. Protein losses and energy expenditure are directly
related to the size of the burn. Nutrition support for the burn patient requires
meeting energy and protein needs. Periodic re assessment of calorie needs
during recovery prevents complications from overfeeding. Providing enough
calories and protein can help minimize loss of lean body mass and enable
healing.
Calorie needs:
Energy needs surge 7 to 10 days post burn. Calorie needs may change due to
change in patient status. Injuries and infections can also increase calorie
requirements.
Best practice is to re assess calorie needs weekly, taking into consideration
changes in condition including extubation, activity, infection, surgery and
frequency of dressing change. Indirect calorimetries, or metabolic carts, provide
the most accurate evaluation of calorie needs when compared to predictive
equations.
Calorie needs will be high before grafting and decrease afterwards. Good
nutrition is needed to heal the donor sites along with the grafted burns.
The metabolic cart can measure energy expenditure (MEE) over a brief period of
time. This information can be extrapolated to twenty four hour caloric
requirements. The results of the metabolic carts can be multiplied by 1.1 to 1.3 if
the patient is active with physical therapy or dressing changes. The timing of the
metabolic cart is key in getting an accurate study. It is helpful for the patient to be
tolerating tube feedings at goal as the metabolic cart is performed.
Predictive equations are another way of assessing calorie needs. Ireton Jones
and Harris-Benedict are two of the predictive equations commonly used in
assessing calorie needs of burn patients. In intubated patients periodic metabolic
carts will give more accurate and useful information when compared to a
predictive equation in determining the calorie needs of burn patients.
BURN CARE MANUAL FAHC
44
Assessment of energy needs:
Key to assessing calorie needs is to get an accurate weight that reflects the
patient’s weight at the time of injury; it may be a stated weight.
Ireton Jones in ventilator dependent patients:
EEE=1784-11(age) +5(weight in kg) +244(if male) +239(if trauma) +804(burn)
Harris Benedict equation (HBE). BEE=Basal Energy Expenditure. The result of
this equation is then multiplied by a stress factor.
Men: BEE=66.5+13.7(wt in kg) +5 (height in cm)-6.8(age years)
Women: BEE=655+9.6(wt in kg) +1.75(height in cm)-4.7(age in years)
Stressors
Activity factor:
Confined to bed
Out of bed
Injury factor:
Minor operation
Skeletal trauma
Major Surgery
Sepsis
Burn factor:
<20% TBSA
20-25% TBSA
25-30% TBSA
30-35% TBSA
35-40% TBSA
40-100% TBSA
Inhalation injury
Stress factors
1.2
1.3
1.2
1.3
1.4
1.6
1.2
1.6
1.7
1.8
1.9
1.9-2
1.5
Protein needs:
Protein needs are also elevated in patients with burns. Typically patients receive
1.5 grams of protein per kg but may require close to 2.5 grams of protein per kg
per day. Although providing high amounts of protein to burn patients will not
ameliorate catabolism, it will contribute to anabolism and enable healing. Protein
is needed to heal burn and graft sites. Patients’ with burns have protein loss due
to loss of skin from the burn itself.
Nutrition support:
Enteral nutrition is best practice in all patients including burns. Enteral nutrition is
better utilized, supports immune function and improves outcome. If enteral
access is safe and available, starting tube feeds early in the patients hospital
BURN CARE MANUAL FAHC
45
stay will decrease ventilator days and length of stay. Patients may also eat if
getting tube fed.
Tube feeds should be initiated in all patients with:
• Burns >20% of TBSA
• Burns >10% with other significant injuries
• Elderly patients
• Patients who will frequently be NPO for surgery/dressing
changes/procedure requiring sedation.
• Patients with baseline nutrition compromise such as a history of
unintentional weight loss.
In patients lacking in safe enteral access Total Parenteral Nutrition (TPN) can be
used as a nutrition source until the patient can be fed enterally. TPN solutions
are customized to the patient individual needs. The TPN is monitored to maintain
it’s safely and usefulness.
Enteral nutrition:
The tube feed of choice for the burn patient on formulary at FAHC now is Crucial.
Crucial is a high protein, high calorie enteral formula. It contains hydrolyzed
casein as a protein source which has been shown to be better absorbed in
critically ill patients. The primary fat source is marine oil. The omega 3 fats in
marine oil act as immunomodulators. It does contain arginine, another nutrient
associated with wound healing. It is supplemented with elevated levels of key
nutrients associated with wound healing. It can be fed into the stomach or small
bowel. Details of the nutrient content of this product are posted on the nutrition
services web site.
http://intranet.fahc.org/Depts/Nutrition/Nutrition_Contrib/Documents/Diet_Order_
Guide.pdf
Typically when tube feedings are started they are run continuously, they can be
run over shorter periods of time to allow time off for meals or therapy. Tube
feedings can act as a sole source of nutrition or as a supplement to a regular
diet.
Crucial is contraindicated in:
•
•
•
•
•
Patients who are septic
Patients who are pregnant
Patients with elevated potassium and renal failure or insufficiency
Patients with liver failure
Patients who are HIV positive
Other tube feed options are available for these populations.
BURN CARE MANUAL FAHC
46
Diet by mouth:
If the patient is able to eat, a regular, high calorie high protein diet is best choice.
In addition to the patients meals, snacks and supplements can provide addition
calories. The supplements available at FAHC are posted on the nutrition services
web site. The best choice supplement is the one the patient will take on a regular
basis. Low sugar supplements are available for patients with diabetes. Lactose
free supplements are also available. The diet tech can assist patient with meal
selection and indicate high protein options on the menu. They will also offer
snacks and supplements.
A complete list of high calorie supplements is available at:
http://intranet.fahc.org/Depts/Nutrition/Nutrition_Contrib/Documents/Diet_Order_
Guide.pdf
The dietitian will also meet with the patient and their family and discussed the
reason for high protein high calorie diet and suggest options from the menu and
supplement on the formulary. At least 3 meals and 2 snacks per day are
encouraged. Nutrition services will accommodate patient’s special requests as
able. Typically patients receive a supplement at every meal.
The aim of providing high calorie supplements to burn patients is to provide
addition calories and protein for healing. The supplements are intended to be
consumed in addition to meals; typically they are not a meal substitute. For
patients who can’t tolerate solid food or are only drinking ensure plus, four to five
cans of ensure plus are needed per day to prove close to adequate calories.
Supplements such as ensure or mighty shakes can be consumed between meals
and in the evenings to avoid interfering with meal time appetite. This is a good
strategy for patients who have a poor appetite or feel full quickly.
Patients often fatigue if consuming the same supplement for a long time, varying
the type of supplement can help patients continue to drink supplements. The best
choice of supplement is the one the patient is willing to consume on a regular
basis. Although ensure plus is the highest in calories, some patients may prefer
mighty shakes or CIB (a fruit juice based supplement).
High protein foods include chicken, turkey, beef, fish, eggs, milk and other dairy
products, and nuts. Good snack choices are sandwiches, yogurt, cottage cheese,
milk, peanut butter or cheese and crackers, egg, tuna or chicken salad. All are
available as between meal snacks.
Other high calorie, high protein foods are available on the patient menu. The
patient will be encouraged to choose these. Also burn patients will be offered
between meal snacks. The overall goal is to allow the patient to maximize calorie
BURN CARE MANUAL FAHC
47
and protein intake for healing. FAHC nutrition services will try to accommodate
special requests.
Supplemental vitamin and nutrients:
Supplemental vitamins are required when healing burns to provide specific
nutrients for healing and to compensate for losses via the burns. Vitamin C is a
component of collagen formation. Zinc is lost when skin or gastrointestinal fluids
are removed/lost. Glutamine is a nutrient that acts as an immunomodulator.
Arginine has been shown to enable wound healing in some studies. Arginine is
contraindicated in septic patients.
In patients taking a regular diet with small burns, likely there is no benefit in
giving supplemental vitamins except a multivitamin and mineral and vitamin D.
Listed below are commonly given supplements, dose and who will most benefit.
Nutrient
Vitamin C
Zinc (ZNSO4)
Multivitamin
and mineral
Vitamin A
Tube fed only
Tube feed
combined with
diet
500 mg per
1000 mg per
day
day
220 mg per
220 mg per
day
day for 14
days
One chewable One chewable
tablet daily
tablet daily
None
None if tube
fed > 1 liter
per day
Vitamin D
None
Arginine
supplement
Glutamine
None
400 IU per
day
None
10 grams 3
times per day
10 grams 3
times per day
Diet only,
large burn
Diet only,
small burn
1000 mg per
day
220 mg per
day for 14
days
One chewable
tablet daily
10,00 iu po
Monday,
Wednesday
and Friday
400 IU bid
None
None
One chewable
tablet daily
none
400 IU daily
Two packets
None
daily
10 grams 3
None
times a day as
tolerated
Monitor:
Monitoring the patients response to nutrition support allows for changes to best
provided nutrition for healing. Nutrition services will review the bedside flow sheet
to see the amount of TPN or tube feed the patient receives. Also, patients eating
by mouth are closely monitored using the flow sheets. Calorie counts can be
implemented in patients who are eating poorly and are candidates for
BURN CARE MANUAL FAHC
48
supplemental tube feeds. Weekly weights are needed to evaluate if the patient is
consuming enough calories.
Labs:
Prealbumin is affected by acute stress and will be low early in the hospital
course. It is not a good indicator of response to nutrition therapy early in the
hospital stay. It can be helpful when the patient is no longer acutely stressed.
Actual nutrient intake is the best way to evaluate nutrition status. Patients, who
are eating poorly, or not at all, either have a nutrition problem or will soon
develop one.
Electrolytes, magnesium and phosphorus should be followed daily in patients
receiving nutrition support.
Close monitor of blood sugars, at least initially, even in non diabetic patients is
needed.
Prepared by
Karen Tufano RD CD
Bonnie Beynnon RD CD CNSD
BURN CARE MANUAL FAHC
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BURN NUTRITION - PEDIATRIC
Burned children pose a special challenge to meet their growth needs. A
burned child has more limited endogenous reserves and greater calorie and
protein needs/kg than an adult so they can more quickly reach negative nitrogen
balance with a smaller burn area than an adult. Also the immaturity of an infant’s
system makes them more susceptible to diarrhea, dehydration and malnutrition.
Children follow the same Ebb and Flow phase as adults after a burn with the
Ebb phase lasting about 3-5 days which is characterized by hypometabolism,
and the flow phase which occurs during the 6-10th days is characterized by
hypermetabolism.
Caloric Needs
The degree of hypermetabolism is directly related to the size of the burn.
Studies in burned children at Shriners Hospitals for Children show that energy
needs approximate the RDA for children, as the increased energy needs for the
burns are offset by decreased activity. This is the calculation generally used
here at FAHC.
RDA
Infants
Birth to 6 months
6-12 months
108 kcal/kg
98 kcal/kg
Children
1-3 years
4-6 years
7-10 years
102 kcal/kg
90 kcal/kg
70 kcal/kg
Male
11-14 years
15-18 years
55 kcal/kg
45 kcal/kg
Female
11-14 years
15-18 years
47 kcal/kg
40 kcal/kg
Another formula which is also for children with burns is the Curreri formula.
This formula is generally not used at this facility.
Monitoring the burned pediatric patient
A nutrition assessment protocol depending on the severity of the patient’s burn
and alertness would include the following:
- A diet history
BURN CARE MANUAL FAHC
50
-
-
Meeting with the patient/family to obtain food preferences, initiate
high calorie, high protein snacks, and possibly supplemental age
appropriate shakes, and/or the addition of modular ingredients to
food foods to boost calorie and protein intake.
Monitoring of calorie and protein intake whether on PO feeds, tube
feeds parenteral nutrition or combination of the above.
Glucose levels may need to be monitored.
Monitoring of Prealbumin.
Vitamin and mineral supplementation may need to be provided.
Bi-weekly weights or more often as deemed necessary.
Nitrogen balance studies if thought that nutrition intake may be
inadequate.
Protein Needs:
Protein needs are elevated in burned pediatric patients, and it is recommended
that 20-23% of the calories be provided as protein with >10% BSA burns which
translates to about 2.5-4.0 grams protein/kg.
Micronutrient Needs:
Micronutrient needs increase based on the severity of the burn, and stores of
micronutrients are lower in a young child. The following are recommendations
for vitamins and mineral supplementation in the burned child: (3)
Children and adolescents (3 years and older)
1. Major burn
- one multivitamin daily
- 500 mg ascorbic acid twice daily
- 10,000 IU vitamin A daily
- 220 mg zinc sulfate daily
2. Minor burn (<20%) or reconstructive patient
- one multivitamin daily
Children (<3 years of age)
1. Major burn
- one children’s multivitamin daily
- 250 mg ascorbic acid twice daily
- 5000 IU vitamin A daily
- 100 mg zinc sulfate daily
2. Minor burn
- one multivitamin daily
Children with burns <20% of body surface area usually can meet their energy
and protein needs with a high calorie, high protein oral diet. Snacks should be
offered along with a multivitamin. High calorie shakes may be offered.
If the patient has a larger burn, energy needs may not be met by oral feeds
alone, and supplemental tube feeds may be needed. Feeding enterally is always
BURN CARE MANUAL FAHC
51
the preferred method, but if the patient is unable to tolerate enteral feeds,
parenteral nutrition may be needed.
References:
1. Young VR, Motil KJ, Burke JF. Energy and protein metabolism in relation to
requirements of the burned pediatric patient. Textbook of Pediatric
Nutrition. New
York, Raven Press; 1981: 309-340.
2. Curreri PW, Richmond D, Marvin J, et al. Dietary Requirements of patients
with major burns. J Am Diet Assoc. 1974; 65: 415-417.
3. Samour PQ, Helm KK, Lang CE, Handbook of Pediatric Nutrition (2nd
edition). Aspen Publishers, Inc. Gaithersburg, Maryland 1999: pg 502.
Prepared by Patty McKibben MS, RD, CD
Edited by Carlie Geer MS, RD, CD and Linda LaShure RD, CD
BURN CARE MANUAL FAHC
52
BURN REHABILITATION
Burn rehabilitation is a
24 hour a day process!!!!
The ultimate goal of burn rehabilitation is to return the patient back to society in
as near to their normal functional capacity as what existed prior to the burn injury,
through prevention and treatment of burn scar contracture deformity and
hypertrophy scarring. This goal is achieved through functional activities, exercise
programs, splinting, positioning, and scar management.
Functional Activities
Outcomes: Prevent loss of function during hospitalization or prevent
secondary complications. Reinforce carry over of ROM and strengthening
exercise programs.
Exercise Programs
Outcomes: Maximize functional ROM and strength through exercise
programs to be carried out by the patient and or caregivers.
Splinting
Outcomes: Protect joints and tendons, provide optimal positioning for
wound and graft healing, maximize and maintain ROM (see photos on following
pages).
BURN CARE MANUAL FAHC
53
S:\Groups\Rehab Therapies\ACUTE\Burn Rehabilitation.doc
BURN CARE MANUAL FAHC
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Positioning “The position of comfort is the position of contracture”
Outcomes: Edema control; prevent tissue destruction.
Maintain burned tissue in and elongated state (see diagram)
*These positions are not indicated for all patients, please review therapist
recommendations closely.
BURN CARE MANUAL FAHC
55
Timelines for development of tissue restrictions
• Burn scar contracture
1 - 4 days
• Tendons and sheaths
5 - 21 days
• Adaptive muscle shortening 2 - 3 weeks
• Ligament and joint capsule 1 - 3 months
Effects of Compression Therapy
• Flattens the scar
• Increases pliability
• Decreases blood flow
• Accelerates scar maturation
• Realigns collagen bundles
• Decreases edema
• Decreases the rate of collagen synthesis
• Compression is mandatory on all burn wounds that require >21 days or skin
grafting to heal
• Compression is required until the scar is mature
• Compression should begin within 2 weeks of wound closure
Frequency of Wear
• All the time except bathing and cream application
• Not off for more than 30 minutes to 1 hour at a time
Duration of Use
• Until scar maturation
• Minimum of 6-8 months; usually 9-12 months; longer in children
As long as a scar is red, it is vascular. It can contract and hypertrophy
Amount of Compression
•Reported clinical improvement with 5 - 15 mm Hg
–Elastic bandage: (coban)
•Extremity: 10-15 mmHg (may need 2 layers)
•Trunk: 3-4 mmHg
–Tubular support bandage: 10-20 mmHg
•Use 2 layers
–Pressure Garment: 25 mm Hg
Elastic Tubular Support Bandages
Advantages
•Used on healed burns that can not tolerate shearing forces
•Interim pressure device
•Comfortable
•Can be placed over dressing
•Controls edema
Disadvantages
•Limited to cylindrical body parts
BURN CARE MANUAL FAHC
56
•Improper application or bunching can cause skin breakdown or edema
•Some patients are allergic to elastic
•Same diameter through out a tapered extremity
Custom Made Elastic Compression Garments
Advantages
•Can be fit for every part of the body
•Customized closures, materials, styles
•Multiple options
•Variety of colors
•Multiple companies
Disadvantages
•Expensive
•Not all insurances reimburse
•Fit - dependent on accurate measurements
•Difficult to don/doff
•May cause skin breakdown
•May retard/alter bone growth
•Weight gain/loss should be stable
Proper Fit of Custom Garments
•Extend garment 2-3“ beyond scar
•Avoid stopping garment over muscle belly or joint
•Anchor garment so it does not slip
•Avoid zippers when possible
•If zippers are needed, avoid placing them over scar and bony prominences
•Initial fitting should not be done by patient at home
•Should be tight enough that it’s difficult to pull away from skin, but does not
compromise neurovascular status
•Avoid wrinkles
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HYPOTHERMIA AND FROSTBITE
Hypothermia
Hypothermia, or exposure, exists when the body core temperature falls below
98oF. The heart rate, cardiac output, respiratory rate, and blood pressure fall. As
the muscles cool, shivering begins, become violent, and then gradually ceases
below 86oF as the muscles become stiff. Central nervous system cooling leads
to a decrease in cerebral blood flow, dilation of the pupils, stupor, and then coma.
Hypothermia may be classified by duration into acute (several minutes to a few
hours), sub-acute (several hours to a day), and chronic (one to many days).
Acutely, there is a large difference between body core and outside temperatures.
In sub-acute and chronic hypothermia, the differences between body core and
shell temperatures are smaller.
In general, hypothermia occurs in one of the following four (4) clinical settings:
Immersion Hypothermia is usually acute or sub-acute and results from
immersion in cold water. A similar hypothermia can be due to exposure to
cold rain and high winds.
Field Hypothermia occurs in previously healthy individuals such as
skiers, climbers, hunters, and hikers and may accompany injuries
occurring outdoors in cold weather.
Urban Hypothermia occurs in individuals with a physical predisposition,
disability, or illness. Predisposing conditions include those which increase
heat loss (premature infants and newborns with relatively large surface
areas), or interference with heat production, i.e., the elderly with impaired
circulation.
Hypothermia occurs when the body core is accidentally cooled to below
98oF. It can be caused by exposure to cold, snow or ice. Hypothermia
requires medical attention as soon as possible. First aid should be applied
to prevent further heat loss and re-warm the body core and extremities.
Patients with hypothermia should be treated gently to avoid heart
problems.
Frostbite:
The term "frostbite" refers to actual localized of body parts to variable depth
depending on the temperature, length of exposure, amount of insulation and
other factors. Frostbite requires temperatures of freezing or below. The most
commonly involved body parts are on an exposed position (face, ears, hands,
and feet). In addition, the body's tendency to protect itself from cold by restricting
peripheral circulation predisposes to frostbite of the extremities.
Localized cold injury results from local freezing and interference with circulation.
Intra-cellular and extra-cellular ice crystals appear and as they grow in size
cause cellular damage.
Superficial frostbite involves only the outer layers of the skin and causes burning
or tingling followed by numbness. Inspection shows a grayish-white patch of skin,
BURN CARE MANUAL FAHC
58
usually on the face or extremities. The deeper tissues remain soft and pliable.
After thawing, the area becomes red and sensitive, and slight edema with a few
small blebs may appear. A few days later, the skin may peel.
Deep frostbite, a much more serious injury, usually occurs in the hands and feet.
Inspection shows a cold, waxy, pale, or cyanotic member, solid and unyielding,
which resembles a piece of chicken just out of the freezer. After thawing, blisters
of various sizes usually develop. A relatively favorable sign is the occurrence of
huge blisters filled with pinkish fluid, extending close to the tips of the affected
digits. In more severe frostbite, the blisters tend to be smaller and filled with a
darker fluid, the part remains numb and cool, and the joints remain stiff. In the
most severe cases, the frozen area is completely numb, cold, and bloodless,
without blisters or edema, and gangrene develops rapidly. The amount of
damage tends to be overestimated in the early stages, and amputation should be
delayed if possible until clear demarcation occurs.
Signs & Symptoms of Frostbite
Tingling and burns are early symptoms and a warning to get out of the cold
immediately. If this isn't possible, vigorously move the affected part to increase
circulation.
The next stage is numbness. By this time, you probably have frostbite.
In the third stage, skin may appear pale or white and cold to the touch.
In the final stages, there is a swelling and blisters may form after the skin thaws.
A physician should examine all frostbite as soon as possible. Prompt treatment
will increase the chance for complete recovery.
Initial Management
Superficial frostbite can be thawed by direct body heat, such as a warm hand on
a frozen cheek, or by general body warming indoors.
The preferred initial treatment for deep frostbite is rapid re-warming on a water
bath at a temperature of 104 - 108oF. Rapid re-warming should not be performed
in the field if there is a danger that the extremity might be frozen. The re-warming
flushing process is quite painful, and narcotics may be required for relief of pain.
Vasodilatation in the affected member is encouraged by raising the body core
temperature with direct heat to other parts of the body and hot drinks.
After thawing, the once frozen part is wrapped in clean, soft material. Toes and
fingers are separated with cotton pledgets, and the limb is elevated to minimize
swelling. Patients should not be allowed to walk on a thawed foot. Smoking is
prohibited.
Tissue loss will be less with rapid re-warming even if the part has been frozen for
several days.
BURN CARE MANUAL FAHC
59
Frostbite protocol
Admission/ED: Rewarm affected areas rapidly in warm water (40-42°C) for 15
to 30 minutes or until thawing is complete.
On completion of re-warming: treat the affected parts as follows:
1. Débride white blisters and institute topical treatment with aloe Vera every
6 hours.
2. Leave hemorrhagic blisters intact and institute topical aloe Vera every 6
hours.
3. Elevate affected parts with splinting as indicated.
4. Administer anti-tetanus prophylaxis (toxoid or Ig).
5. Provide analgesia: opiate IV/PO PRN.
6. Administer ibuprofen 4-600 mg orally Q 12 hours.
7. Administer penicillin 500 mg PO Q 6 hours for 48 to 72 hours.
8. Begin ASAP QD hydrotherapy (PT consult) for 30 to 45 min. @40°C. Until
devitalized tissue sloughs. Less benefit if delayed >48 hr.
9. Documentation: obtain photographic records at
a. Admission
b. 24 hours
c. Every 2 to 3 days until discharge.
10. Smoking: Prohibit the patient from smoking/nicotine.
11. After hydrotherapy has reached maximal benefit, switch to
bacitracin/Sulfamylon/silvadene as indicated.
12. Debridement is carried out PRN in the office setting or in the OR over the
next 1-2 months.
13. Consider contacting interventional radiology or vascular for possible tPA,
reserpine, or other angiographic revascularization of cold, insensate but
not necrotic extremities (i.e. early intervention). There is some literature
showing benefit. Consult Drs. Morris, Najerian, Bhave or Sartorelli for
guidance if unsure if patient is candidate for angiographic intervention.
Adapted from Murphy JV, Banwell PE, Roberts AH, et al. Frostbite: pathogenesis
and treatment. J Trauma 2000;48(1):171-8; Gentilello LM, Rifley W. Continuous
arteriovenous rewarming: report of a new technique for treating hypothermia. J
Trauma 1991;31:1151-4; Reduction of the Incidence of Amputation in Frostbite
Injury With Thrombolytic Therapy. Bruen, K. J., MD, et al. Arch
Surg. 2007;142:546-553.
BURN CARE MANUAL FAHC
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PEDIATRIC BURNS:
SPECIAL
CONSIDERATIONS
Highlights of ABA Burn Admission Criteria related to children
•
•
•
•
•
Age < 10 with greater than 10% TBSA burns- second and third degree
Age > 10 with 20% TBSA burns
Third degree burns > 5%
Burns to face , hands, feet, genitalia, or overlying major joint
Suspected Abuse: Mechanism of injury is consistent with developmental
status and must match clinical picture
It bears repeating:
• < 10% Burns- start on maintenance with fluid bolus as needed
• Pediatric Parkland formula for 2nd and 3rd degree
o 2-4 ml RL X kg X % BSA burn
o ½ in 1st 8 hrs
o ¼ in 2nd 8 hrs
o ¼ in 3rd 8 hrs
o In children, must add dextrose containing maintenance IV fluids in
addition to resuscitation: – use D5LR100cc/kg for 10 kg of weight
ƒ 50 cc/kg next 10 kg of weight
ƒ 20cc/kg remaining weight
Goals:
Urine output of 0.5 cc/hr (1-2 cc/kg/hour for children)
Reverse base deficit
Restore blood pressure
Caring for Children
Children’s needs and understanding of the injury will differ based upon their
stage of development.
BURN CARE MANUAL FAHC
61
Key developmental considerations include:
• Infants: Learn through sensory stimulation and movement, including
touch, may experience separation anxiety
• Early Childhood: At risk for developing low self-esteem as they may view
the injury as punishment for being “bad’, coordinate procedures around
daily routines
• School-Age: Decrease anxiety by educating child and involving in care as
much as possible
• Adolescence: Concern with body image, at increased risk of depression
however, may not share feelings with others. Consider psychological
counseling
Support for the child and family is critical. When children are frightened and
uncomfortable, they may regress to the developmental level that allows them to
deal with the stress of the injury. They may be confused by the intensity of
concern given to their physical needs and care. All children need reassurance
that they are “all right” and that they will get better.
General Care Guidelines include:
• Tell child first before doing anything
• Allow for choices whenever possible
• Give descriptions of sensations that may be felt as well as what child can
do to cope with them
• Do not use words such as “done” or “finished” until burn care is completed
• Avoid emotional words such as “pain”, “scream” or “hurt”
• Utilize treatment rooms or spaces other than child’s bedroom for dressing
changes and interventions -in order to maintain a “safety zone”
• Establish ground rules before procedure. For example, agree on an
allotted time for dressing change or to identify who may perform what
piece of dressing change
• If child refuses to focus on dressing change or refuses to actively
participate- continue to encourage cooperation. Reinforce with praise and
gradually increase expectations for child’s participation in care
• If child cannot help- encourage child to count 1-10 or 20 as fast as
possible, rest for agreed upon time ( another 1-10 or 20), then continue
burn care work , repeating pattern as indicated
Child Life Specialists are available throughout FAHC to provide procedural
support and medical play opportunities for children and families, including
siblings.
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62
Managing Pain
Children can enter a “shock like” state after an injury that can mask their
expressive ability. It is critical to remember that the child’s initial experience
with pain sets the stage for the rest of the hospitalization.
Barriers:
• Younger children have difficulty conceptualizing or quantifying pain.
• Older children have difficulty in describing pain due to lack of experience
• Often non-pharmacologic techniques are under -used.
Developmentally Appropriate Interventions
Ages 0-2
Distraction
Ages 2-6
Deep Breathing, Distraction
Ages 6 and older
Deep Breathing, Distraction, Imagery, Progressive
Muscle Relaxation
It is sometimes difficult to predict the most effective pain management for
children with new burns, but providing a dose that gives the maximum coverage
for pain and anxiety is optimal.
Pharmacological Support:
• Give IV doses immediately before interventions
• Give PO doses 45 minutes to 1 hour before
Frequently used medications and dosages:
Morphine IV
0.1 mg/kg/dose
Fentanyl IV
1-5 mcg/kg/dose
Versed IV
0.05 mg/kg/dose
Oxycodone PO
0.15-0.4 mg/kg/dose
Versed PO
0.5-1 mg/kg/dose
Tylenol
10-15mg/kg/dose
Ibuprofen
10mg/kg/dose
•
•
Assess the need for anesthesia support for Propofol or additional
medications
Consider PACT team consult for complex pain management
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PSYCHOSOCIAL ASPECTS OF BURNS
Psychosocial aspects of the burn survivor –
Patients with burn injuries are a very unique population not only in terms of the
physical treatment and recovery but also the psychosocial aspects of recovery.
The first challenge that a patient with a burn injury faces is survival. Their focus
changes to the psychosocial aspects of recovery as the rate of survival
increases.
Burn patients go through various stages of emotional recovery as their physical
recovery continues to progress. Each patient is an individual and their emotional
journey through recovery will be unique. Many factors determine how someone
will respond and cope with the traumatic injury including the events surrounding
the trauma, fatalities involved, and preexisting psychosocial issues.
The emotional responses that one has to such events will span the spectrum and
vary with each individual. There is no right, wrong or “appropriate” way for
individuals to react it is their process.
Some emotional responses you might observe are anxiety, depression, sleep
disturbances and grief, all of which are very normal.
The best way we can support individuals is to honor and respect where they are
& try to meet their emotional and physical needs.
There are very valuable resources within our hospital including social work,
medical psychology and child life specialists, all of whom have knowledge, skills
and expertise in supporting individuals and their families through this process.
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64
BURN CARE REMINDERS
Burn clinic number 802-847-3790
WOUND CARE
1. Shower daily with a mild soap.
2. Pat all areas dry.
3. Apply prescribed topicals and/or lotions per discharge summary. Cover
all areas so that you cannot see any burn or healed areas through it.
Don’t forget to reapply!
4. Once topicals and/or lotions have been applied, bandage burns if
directed.
5. **Remember new skin is fragile and may tear, bruise, or blister if
bumped. Apply bacitracin to these areas & watch this area closely. **
ITCHING
1. Itching is a common problem in the wound healing process.
2. Tips to relieve itching include:
a. Applying Eucerin or other non-perfume moisturizing cream more
frequently, especially before bed time.
b. Cool compresses
c. Benadryl may help to decrease discomfort. Apply more ointment
as a first step. **If using must read label & follow directions.
d. Loose fitting clothing.
AVOID EXPOSURE TO HOT AND COLD, DIRECT SUNLIGHT
1. Hot Weather: Your new skin is less able to tolerate extreme
temperature:
a. Deep burn tissue has a decreased ability to sweat so you may
experience more heat discomfort. Stay indoors in a cool room if
this occurs.
b. Go outside in the evening when it is cooler out.
c. Stay in the shade if outdoors during warm weather.
d. Keep burned skin covered while outdoors (long sleeves, pants,
hat, gloves, etc.)
e. New skin will burn and blister if exposed to direct sunlight. Must
use a sunscreen with the highest SPF you can find.
f. The risk of scarring increases with exposure to extremes of hot,
cold and direct sunlight. This risk lasts up to one year on
burned skin and on skin grafts.
2. Cold Weather: Your burned skin is very sensitive to cold and is at high
risk for frostbite. Dress warmly!
a. If you experience numbness, tingling or change in the color of
your skin, get out of the cold.
b. Wear gloves or mittens. If your face is burned, cover it with a
scarf.
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65
SCARRING
1. Initially it is very difficult to tell how much scarring will be permanent. It
is difficult to predict how much scarring any one person will have since
the amount of scarring is determined on an individual basis and by the
depth of your burn. When you return to clinic you will be evaluated for
the possible need for pressure garments. If you have been grafted
(split thickness skin graft) you will almost always require pressure
garments, all others will be evaluated on an individual basis.
EXERCISE
1. Per physical and occupational therapy instructions.
DIET
1. A healthy, high protein diet is preferable and will promote wound
healing. You may need to supplement your diet with Ensure, Carnation
Instant Breakfast, or other protein shakes.
a. High Protein Food- Dairy (milk, cheese, yogurt, eggs), Poultry, Beef,
Fish (tuna, etc), certain nuts, or Peanut butter.
EMOTIONAL READJUSTMENT
1. If you are having anxiety, sadness, or sleep issues related to this injury
please do not hesitate to call the burn clinic (847-3790) or discuss this
at your next appointment.
FOLLOW-UP
1. Keep all appointments. Burn clinic is located on the 5th Floor of the ACC
building. 847-3790
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66
WEBSITE REFERENCES
www.ameriburn.org
www.burnprevention.org
www.burntalk.com
www.nfpa.org
www.burntherapist.com
www.firefightersburninstitute.com
www.cdc.gov
www.traumaf.org
www.shrinershq.org/Hospitals
www.burnsurgery.org
www.sagediagram.com
www.wounds1.com
www.phoenix-society.org
BURN CARE MANUAL FAHC
American Burn Association
Burn Prevention Foundation
Burn Talk
National Fire Protection
Association
Burn Therapist
Firefighters Burn Institute
Centers for Disease Control
The Trauma Foundation
Shriners Hospitals for
Children
Burn Surgery
Sage Diagram
Wounds1-burn dressings
Phoenix Society for Burn
Survivors
67
BURN (Dressing change) CART INFORMATION
The burn cart was developed as a need for patient care units to get burn supplies
they normally do not stock on their units. The cart is located in distribution and
will be re-stocked by distribution when returned.
To request the cart;
The unit enters the request in transport tracking and distribution is notified to
bring the cart to that particular unit. Please give plenty of notice before you wish
to have the cart ready. It can be obtained through this mechanism 24 hours a
day.
The cart should be kept outside the room.
To return the cart:
The cart is returned through transport tracking as soon as burn care is
completed.
Record items used on PAR sheet in top drawer of cart.
Restocking of the cart only occurs during regular business hours. If you need
additional items contact distribution through your normal channels
Currently the Mepilex, Mepitel and large Telfa are kept in CSR. Unit staff will
need to go to CSR to get these products.
The large burn jacket is a patient charge and should be charged accordingly.
See attached sheet for contents
BURN CARE MANUAL FAHC
68
Burn Cart Charge Master Form
Floor Name:
CC#
Approver Name:
M#:
Time Cart Delivered
to Dept.
Exp. Date
01/01/2010
Item #
Time Cart
Returned:
New
Item #
Product
PAR ON
CART
Unit of Measure
009291
001988
Hibiclens 16 oz
Sterile Bowls
4
2
bottles
each
55408
Telfa 3 X 8
2
boxes
001777
001763
Telfa 3 X 2
Ace Bandage 2" non sterile
2
2
boxes
rolls
001764
Ace Bandage 3" non sterile
4
rolls
001765
Ace Bandage 4" non sterile
4
rolls
001766
Ace Bandage 6" non sterile
4
rolls
001839
Kerlix
20
rolls
55418
Lap Sponges
6
packs
01/01/2001
001872
Exu-dry dressing 24x36
2
each
05/01/2010
001873
Exu-dry dressing 15x24
6
each
08/01/2010
001874
Exu-dry Dressing 9x15
15
each
001875
Exu-dry Jacket Large
2
each
001878
Exu-dry gloves Small
2
each
001880
Exudry Buttock Dressing Adult
2
each
001881
Exu-dry Jacket Small
1
each
001882
Exu-dry gloves Medium
2
each
08/01/2010
12/01/2010
001903
59036
Bandnet Size # 3
1
box
001905
59037
Bandnet Size # 6
1
box
001906
59038
Bandnet Size # 8
1
box
001907
59039
Bandnet Size # 10
1
box
002044
Exu-dry gloves Large
4
each
020217
Burn Fluff Dressing/large
12
packs
001771
Conform - kling 2"
1
box
001772
Conform - kling 3"
1
box
55407
Conform - kling 4"
4
rolls
012247
Dermal Gloves Small
2
pair
012248
Dermal Gloves Medium
2
pair
012249
Dermal Gloves Large
2
pair
012250
Dermal Gloves X-Large
2
pair
BURN CARE MANUAL FAHC
Write Down Qty
used
69