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Published on : Mar 14, 2014
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Slide 1 - Burn Injuries By Donald Hudson, D.O., FACEP/ACOEP
Slide 2 - Epidemiology Tissue injury caused by thermal, electrical, or chemical agents Can be fatal, disfiguring, or incapacitating ~ 1.25 million burn injuries per year 45,000 hospitalized per year 4500 die per year (3750 from housefires) 3rd largest cause of accidental death
Slide 3 - Risk Factors Fire/Combustion Firefighter Industrial Worker Occupant of burning structures Chemical Exposure Industrial Worker Electrical Exposure Electrician Electrical Power Distribution Worker
Slide 4 - Anatomy and Physiology of Skin
Slide 5 - Skin Largest body organ. Much more than a passive organ. Protects underlying tissues from injury Temperature regulation Acts as water tight seal, keeping body fluids in Sensory organ
Slide 6 - Skin Injuries to skin which result in loss, have problems with: Infection Inability to maintain normal water balance Inability to maintain body temperature
Slide 7 - Skin Two layers Epidermis Dermis Epidermis Outer cells are dead Act as protection and form water tight seal
Slide 8 - Skin Epidermis Deeper layers divide to produce the stratum corneum and also contain pigment to protect against UV radiation Dermis Consists of tough, elastic connective tissue which contains specialized structures
Slide 9 - Skin Dermis - Specialized Structures Nerve endings Blood vessels Sweat glands Oil glands - keep skin waterproof, usually discharges around hair shafts Hair follicles - produce hair from hair root or papilla Each follicle has a small muscle (arrectus pillorum) which can pull the hair upright and cause goose flesh
Slide 10 - Burn Injuries
Slide 11 - Burn Injuries Potential complications Fluid and Electrolyte loss  Hypovolemia Hypothermia, Infection, Acidosis  catecholamine release, vasoconstriction Renal or hepatic failure Formation of eschar Complications of circumferential burn
Slide 12 - Burn Injuries An important step in management is to determine depth and extent of damage to determine where and how the patient should be treated
Slide 13 - Types of Burn Injuries Thermal burn Skin injury Inhalation injury Chemical burn Skin injury Inhalation injury Mucous membrane injury Electrical burn Lightning Radiation burn
Slide 14 - Depth Classification Superficial Partial thickness Full thickness
Slide 15 - Burn Classifications 1st degree (Superficial burn) Involves the epidermis Characterized by reddening Tenderness and Pain Increased warmth Edema may occur, but no blistering Burn blanches under pressure Example - sunburn Usually heal in ~ 7 days
Slide 16 - Burn Classifications First Degree Burn(Superficial Burn)
Slide 17 - Burn Classifications 2nd degree Damage extends through the epidermis and involves the dermis. Not enough to interfere with regeneration of the epithelium Moist, shiny appearance Salmon pink to red color Painful Does not have to blister to be 2nd degree Usually heal in ~7-21 days
Slide 18 - Burn Classifications 2nd Degree Burn(Partial Thickness Burn)
Slide 19 - Burn Classifications 3rd degree Both epidermis and dermis are destroyed with burning into SQ fat Thick, dry appearance Pearly gray or charred black color Painless - nerve endings are destroyed Pain is due to intermixing of 2nd degree May be minor bleeding Cannot heal and require grafting
Slide 20 - Burn Classifications 3rd Degree Burn(Full Thickness burn)
Slide 21 - Burn Injuries Often it is not possible to predict the exact depth of a burn in the acute phase. Some 2nd degree burns will convert to 3rd when infection sets in. When in doubt call it 3rd degree.
Slide 22 - Body Surface Area Estimation Rule of Nines Adult Palm Rule
Slide 23 - Body Surface Area Estimation Rule of Nines Peds For each yr over 1 yoa, subtract 1% from head and add equally to legs Palm Rule
Slide 24 - Burn Patient Severity Factors to Consider Depth or Classification Body Surface area burned Age: Adult vs Pediatric Preexisting medical conditions Associated Trauma blast injury fall injury airway compromise child abuse
Slide 25 - Burn Patient Severity Patient age Less than 2 or greater than 55 Have increased incidence of complication Burn configuration Circumferential burns can cause total occlusion of circulation to an area due to edema Restrict ventilation if encircle the chest Burns on joint area can cause disability due to scar formation
Slide 26 - Critical Burn Criteria 30 > 10% BSA 20 > 30% BSA >20% pediatric Burns with respiratory injury Hands, face, feet, or genitalia Burns complicated by other trauma Underlying health problems Electrical and deep chemical burns
Slide 27 - Moderate Burn Criteria 30 2-10% BSA 20 15-30% BSA 10-20% pediatric Excluding hands, face, feet, or genitalia Without complicating factors
Slide 28 - Minor Burn Criteria 30 < 2% BSA 20 < 15% BSA <10% pediatric 10 < 20% BSA
Slide 29 - Thermal Burn Injury Pathophysiology Emergent phase Response to pain  catecholamine release Fluid shift phase massive shift of fluid - intravascular  extravascular Hypermetabolic phase  demand for nutrients  repair tissue damage Resolution phase scar tissue and remodeling of tissue
Slide 30 - Thermal Burn Injury Pathophysiology Jackson’s Thermal Wound Theory Zone of Coagulation area nearest burn cell membranes rupture, clotted blood and thrombosed vessels Zone of Stasis area surrounding zone of coagulation inflammation, decreased blood flow Zone of Hyperemia peripheral area of burn limited inflammation, increased blood flow
Slide 31 - Thermal Burn Injury Pathophysiology Eschar formation Skin denaturing hard and leathery Skin constricts over wound increased pressure underneath restricts blood flow Respiratory compromise secondary to circumferential eschar around the thorax Circulatory compromise secondary to circumferential eschar around extremity
Slide 32 - Assessment & Management - Thermal Injury Remove to safe area, if possible Stop the burning process Extinguish fire - cool smoldering areas Remove clothing and jewelry Cut around areas where clothing is stuck to skin Cool adherent substances (Tar, Plastic)
Slide 33 - Assessment & Management - Thermal Injury Pertinent History How long ago? What care has been given? What burned with? Burned in closed space? Products of combustion present? How long exposed? Loss of consciousness? Past medical history?
Slide 34 - Assessment & Management - Thermal Injury Airway and Breathing Assess for potential airway involvement soot or singing involving mouth, nose, hair, face, facial hair coughing, black sputum enclosed fire environment Assist ventilations as needed 100% oxygen via NRB if: Moderate or critical burn Patient unconscious Signs of possible airway burn/inhalation injury History of exposure to carbon monoxide or smoke
Slide 35 - Assessment & Management - Thermal Injury Airway and Breathing (cont) Respiratory rates are unreliable due to toxic combustion product’s May cause depressant effects Be prepared to intubate early if patient has inhalation injuries Prep early for RSI
Slide 36 - Assessment & Management - Thermal Injury Circulatory Status Burns do not cause rapid onset of hypovolemic shock If shock is present, look for other injuries Circumferential burns may cause decreased perfusion to extremity
Slide 37 - Assessment & Management - Thermal Injury Other Assess Burn Surface Area & Associated Injuries Analgesia Avoid topical agents except as directed by local burn centers e.g. silvadene Fluid Therapy
Slide 38 - Assessment & Management - Thermal Injury Consider Fluid Therapy for >10% BSA 30 >15% BSA 20 >30-50% BSA 10 with accompanying 20 LR using Parkland Burn Formula 4 (2-4) cc/kg/% burn 1/2 in first 8 hours 1/2 over 2nd 16 hours
Slide 39 - Assessment & Management - Thermal Injury Fluid therapy Objective HR < 110/minute Normal sensorium (awake, alert, oriented) Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi) Resuscitation formula’s provide estimates, adjust to individual patient responses Start through burn if necessary, upper extremities preferred Monitor for Pulmonary Edema
Slide 40 - Assessment & Management - Thermal Injury Analgesia Morphine Sulfate 2-3 mg repeated q 10 minutes titrated to adequate ventilations and blood pressure 0.1 mg/kg for pediatric May require large but tolerable total doses
Slide 41 - Assessment & Management - Thermal Injury Treat Burn Wound Low priority - After ABC’s and initiation of IV’s Do not rupture blisters Cover with sterile dressings Moist: Controversial, limit to small areas (<10%) or limit time of application Dry: Use for larger areas due to concern for hypothermia Cover with burn sheet No “Goo” on burn unless directed by burn center
Slide 42 - Assessment & Management - Thermal Injury Transport Considerations Appropriate Facility Burn Center or Not Factor to consider Burn Patient Severity Criteria Critical, Moderate, Minor Burn Criteria Confounding factors Transport resources
Slide 43 - Inhalation Injury Anticipate respiratory problems: Head, Face, Neck or Chest Nasal or eyebrow hairs are singed Hoarseness, tachypnea, drooling present Loss of consciousness in burned area Nasal/Oral mucosa red or dry Soot in mouth or nose Coughing up black sputum In enclosed burning area (e.g. small apartment)
Slide 44 - Inhalation Injury Burned or exposed to products of combustion in closed space Cough present, especially if productive of carbonaceous sputum Any patient in fire has potential of hypoxia and Carbon monoxide poisoning
Slide 45 - Inhalation Injury Supraglottic Injury Susceptible to injury from high temperatures May result in immediate edema of pharynx and larynx Brassy cough Stridor Hoarseness Carbonaceous sputum Facial burns
Slide 46 - Inhalation Injury Subglottic Injury Rare injury Injury to Lung parenchyma Usually due to superheated steam, aspiration of scalding liquid, or inhalation of toxic chemicals May be immediate but usually delayed Wheezing or Crackles Productive cough Bronchospasm
Slide 47 - Inhalation injury Other Considerations Toxic gas inhalation Smoke inhalation Carbon Monoxide poisoning Thiocyanate poisoning Thermal burns Chemical burns
Slide 48 - Inhalation Injury Management Airway, Oxygenation and Ventilation Assess for airway edema early and often Consider early intubation, RSI When in doubt oxygenate and ventilate High flow oxygen Bronchodilators may be considered if bronchospasm present Diuretics not appropriate for pulmonary edema
Slide 49 - Inhalation Injury Management Circulation Treat for Shock (rare) IV Access LR/NS large bore, multiple IVs Titrate fluids to maintain systolic BP and perfusion Avoid MAST/PASG
Slide 50 - Inhalation Injury Management Other Considerations Assess for other Burns and Injuries Treat burn soft tissue injury Treat associated inhalation injury/poisoning Cyanide poisoning antidote kit Positive pressure ventilation Hyperbaric chamber (carbon monoxide poisoning) Transport considerations Burn Center Hyperbaric chamber
Slide 51 - Chemical Burns Usually associated with industrial exposure First Consideration: Should you be here? Does the patient need decontamination before treatment? Burning will continue as long as the chemical is on the skin
Slide 52 - Chemical Burns Acids Immediate coagulation-type necrosis creating an eschar though self-limiting injury coagulation of protein results in necrosis in which affected cells or tissue are converted into a dry, dull, homogeneous eosinophilic mass without nuclei
Slide 53 - Chemical Burns Bases (Alkali) Liquefactive necrosis with continued penetration into deeper tissue resulting in extensive injury characterized by dull, opaque, partly or completely fluid remains of tissue Dry Chemicals Exothermic reaction with water
Slide 54 - Chemical Burn Management Definitive treatment is to get the chemical off! Begin washing immediately - removal the patient’s clothing as you wash Watch for the socks and shoes, they trap chemicals
Slide 55 - Chemical Burn Management Liquid Chemicals wash off with copious amounts of fluid Dry Chemicals brush away as much of the chemicals as possible then wash off with large quantities of water Flush for 20-30 minutes to remove all chemicals
Slide 56 - Chemical Burn Management Do not attempt neutralization can cause additional chemical or thermal burns from the heat of neutralization Assess and Deliver secondary care as with other thermal and inhalation burns
Slide 57 - Chemical Burn to Eye Management Flood the eye with copious amounts of water only Never place chemical antidote in eyes Flush using LR/NS/H2O from medial to lateral for at least 15 minutes Nasal Cannula IV Ad Set Remove contact lenses May trap irritants
Slide 58 - Specific Chemical Considerations Dry lime Brush off Dry lime is water activated Then flush with copious amounts of water Phenol Not water soluble If available, use alcohol before flushing except in eyes If unavailable, use copious amounts of water
Slide 59 - Specific Chemical Considerations Sodium/Potassium metals Reacts violently on contact with H20 Requires large amounts of water Sulfuric Acid Generates heat on exposure to H2O (exothermic) Wash with soap to neutralize or use copious amounts H2O Tar Burns Use cold packs Do not pull off, can be dissolved later
Slide 60 - Specific Chemical Considerations Chemical Mace CN or CS First chemical agents used by police/military Mucous membrane and respiratory tract irritant Skin sensitizer Management Treat respiratory distress Continued irrigation and shower decontamination Protect yourself first Decontaminate everything afterward
Slide 61 - Specific Chemical Considerations Chemical Mace OC Commonly referred to as “pepper spray” Not as toxic as CN or CS Mucous membrane irritant and skin sensitizer May cause respiratory irritation Management Treat respiratory distress Continued irrigation and shower decontamination Protect yourself first Decontaminate everything afterward
Slide 62 - Electrical Burns Usually follows accidental contact with exposed object conducting electricity Electrically powered devices Electrical wiring Power transmission lines Can also result from Lightning Damage depends on intensity of current
Slide 63 - Electrical Burns Current kills, voltage simply determines whether current can enter the body Ohm’s law: I=V/R Electrical follows shortest path to ground Low Voltage usually cannot enter body unless: Skin is broken or moist Low Resistance (follows blood vessels/nerves) High Voltage easily overcomes resistance
Slide 64 - Electrical Burns Severity depends upon: what tissue current passes through width or extent of the current pathway AC or DC duration of current contact
Slide 65 - Electrical Burns Most damage done is due to heat produced as current flows through tissues Skin burns where current enters and leaves can be almost trivial looking Everything between can be cooked Higher voltage may result in more obvious external burns
Slide 66 - Electrical Burns Alternating Current (AC) Tetanic muscle contraction may occur resulting in: Muscle injury Tendon Rupture Joint Dislocation Fractures Spasms may keep patient from freeing oneself from current
Slide 67 - Electrical Burns Contact with Alternating Current can also result in: Cardiac arrhythmias Apnea Seizures
Slide 68 - Electrical Burns In addition to contact burns, patients can also develop flash burns when the current arcs near them Flame burns may occur when clothing ignites after exposure to electrical current
Slide 69 - Electrical Burns Lightning HIGH VOLTAGE!!! Injury may result from Direct Strike Side Flash Severe injuries often result Provides additional risk to EMS provider Weather capable of producing lightning is still in the area
Slide 70 - Electrical Burns Pathophysiology of Injuries External Burn Internal Burn Musculoskeletal injury Cardiovascular injury Respiratory injury Neurologic injury Rhabdomyolysis and Renal injury
Slide 71 - Electrical Burn Management Make sure current is off Lightning hazards Do not go near patient until current is off ABC’s Ventilate and perform CPR as needed Oxygen ECG monitoring Treat dysrhythmias
Slide 72 - Electrical Burn Management Rhabdomyolysis Considerations Fluid? Dopamine? Assess for additional injuries Consider transport to trauma center
Slide 73 - Electrical Burn Management Any patient with an electrical burn regardless of how trivial it looks needs to go to the hospital. There is no way to tell how bad the burn is on the inside by the way it looks on the outside.
Slide 74 - Radiation Exposure Waves or particles of energy that are emitted from radioactive sources Alpha radiation large, travel a short distance, minimal penetrating ability can harm internal organs if inhaled, ingested or absorbed Beta radiation small, more energy, more penetrating ability usually enter thru damaged skin, ingestion or inhalation Gamma radiation & X-rays most dangerous penetrating radiation may produce localized skin burns and extensive internal damage
Slide 75 - Radiation Exposure Radiation exposure may result in: external injury contamination incorporation injury combined injuries
Slide 76 - Radiation Exposure Effect of Injury dependent upon: duration of exposure distance from the source shielding At risk for delayed complications
Slide 77 - Radiation Exposure Management SAFETY!!! Two Most Useful Tools for Radiation Incident Management Protective Equipment Need for decontamination Likelihood of survival ABCs and Supportive Care
Slide 78 - Pediatric Burns Thin skin increases severity of burning relative to adults Large surface/volume ratio rapid fluid loss increased heat loss  hypothermia Delicate balance between dehydration and overhydration Immature immunological response  sepsis Always consider possibility of child abuse
Slide 79 - Geriatric Burns Decreased myocardial reserve fluid resuscitation difficulty Peripheral vascular disease, diabetes slow healing COPD increases complications of airway injury Poor immunological response - Sepsis % mortality ~= age + % BSA burned