BURNS

DJORGENMORRIS

1. Chapter 6 Burns

2. Topics Introduction to Burn Injuries Anatomy and Physiology of the Skin Pathophysiology of Burns Assessment of Thermal Burns Management of Thermal Burns Assessment and Management of Electrical, Chemical, and Radiation Burns Bla bla bla bla

3. Introduction to Burn Injuries

4. Introduction to Burn Injuries 1.25 – 2 million Americans treated for burns annually 45,000 require hospitalization 90% of burns can be prevented 3 – 5% considered life threatening 2nd leading cause of death for children <12 Half of all tap-water burns occur to children <5

5. Introduction to Burn Injuries Greatest Risk Very young and very old Infirm Firefighters Metal smelters Chemical workers Drugs and alcohol play major role

6. Alcohol plays a major role

7. Introduction to Burn Injuries Reducing burn injuries Improved building codes Safer construction techniques Sprinkler systems Use of smoke detectors Educational campaigns aimed primarily at school children

8. Anatomy and Physiology of the Skin

9. Anatomy and Physiology of the Skin Layers Epidermis Dermis Subcutaneous Underlying structures Fascia Nerves Tendons Ligaments Muscles Organs

10. Anatomy and Physiology of the Skin Functions of the Skin Protection from infection Sensory organ Temperature Touch Pain Controls loss and movement of fluids Temperature regulation Insulation from trauma Flexible to accommodate free body movement

11. Pathophysiology of Burns

12. Pathophysiology of Burns Disruption of proteins in the cell membranes Causes Thermal Electrical Chemical Radiation energies

13. Thermal Burns Molecular structure changed by heat Extent of burn damage depends on: Temperature of agent Concentration of heat Duration of contact

14. Thermal Burns Jackson’s Theory of Thermal Wounds Zone of Coagulation Area in a burn nearest the heat source Suffers the most damage as evidenced by clotted blood and thrombosed blood vessels Zone of Stasis Characterized by decreased blood flow Zone of Hyperemia Increased blood flow

15. Jackson’s Theory of Thermal Wounds Zone of Hyperemia Zone of Stasis Zone of Coagulation

16. Thermal Burns Emergent Phase (Stage 1) Pain response Catecholamine release Tachycardia Tachypnea Mild hypertension Mild anxiety

17. Thermal Burns Fluid Shift Phase (Stage 2) Length 18 – 24 hours Begins after emergent phase Reaches peak in 6 – 8 hours Damaged cells initiate inflammatory response: Vasodilation Increased capillary permeability Intravascular hypovolemia Extravascular edema

18. Thermal Burns Hypermetabolic Phase (Stage 3) Large increase in the body’s need for nutrients as it repairs itself Fluid and electrolytes begin to move back into the vasculature Influx of fluid within vascular space causes the GFR to increase, leading to diuresis Fluid shifts may lead to hypernatremia and hypokalemia Cardiac workload and O 2 consumption increase

19. Thermal Burns Resolution Phase (Stage 4) Scar formation General rehabilitation; progression to normal function

20. Electrical Burns Terminology Voltage – the pressure Difference of electrical potential between two points Different concentrations of electrons Amperes – the velocity Strength of electrical current Resistance (Ohms ) – the friction Opposition to electrical flow

21. Electrical Burns Greatest heat occurs at the points of resistance: Entrance and exit wounds Dry skin = greater resistance Wet Skin = less resistance Longer the contact, the greater the potential of injury Increased damage inside body Smaller the point of contact, the more concentrated the energy, the greater the injury

22. Electrical Burns Electrical Current Flow Tissue of less resistance Blood vessels Nerve Tissue of greater resistance Muscle Bone

23. Chemical Burns Chemicals destroy tissue Acids Form a thick, insoluble mass where they contact tissue Coagulation necrosis Limits burn damage Alkalis Destroy cell membrane through liquefaction necrosis Deeper tissue penetration and deeper burns © Roy Alson, PhD, MD, FACEP, FAAEM

24. Coagulation Necrosis

25. Alkali Burn

26. Radiation Injury Radiation Transmission of energy Nuclear energy Ultraviolet light Visible light Heat Sound X-rays Radioactive Substance Emits ionizing radiation Radionuclide or radioisotope

27. Types of Radiation Alpha Very weak energy source Only significant if ingested Beta Can travel 6 to 10 feet May penetrate clothing Gamma Most powerful type of ionizing radiation Penetrates entire body Neutron Great penetrating power

28. Radiation Injury Exposure can occur through two mechanisms: Direct exposure to a strong radioactive source Contamination by dust, debris, or fluids that contain very small particles of radioactive material

29. Radiation Injury Three factors are important to remember: Duration The longer exposed, the more absorption Distance Travel farther from the source for safety Shielding The more material between you and the source, the less radioactive exposure you experience

30. Radiation Injury Radiation exposure is measured with a Geiger counter Cumulative exposure is recorded by a device called a dosimeter © Ogunquit, Maine Fire-Rescue © Jeff Forster

31. Radiation Injury Different tissues are sensitive to different levels of absorbed radiation Signs and symptoms of exposure Nausea and fatigue Anorexia, vomiting, diarrhea, and malaise Erythema of the skin Confusion Watery diarrhea Physical collapse Long-term effects include cancer and sterility

32. Inhalation Injury Toxic Inhalation Synthetic resin combustion More common than thermal injury Carbon Monoxide Poisoning Colorless, odorless, tasteless gas Byproduct of incomplete combustion of carbon products Suspect with faulty heating unit

33. Inhalation Injury Airway Thermal Burn Supraglottic structures absorb heat and prevent lower airway burns Moist mucosa lining the upper airway Injury is common from superheated steam Symptoms: Stridor or “crowing” inspiratory sounds Singed facial and nasal hair Black sputum or facial burns Progressive respiratory obstruction and arrest due to swelling

34. Depth of Burn Depth of burn damage is normally classified into three categories

35. Burn Depth Superficial Burn Red Painful Dry (no blisters)

36. Burn Depth Partial-Thickness Burn Red or White Painful Blisters (wet)

37. Burn Depth Full-Thickness Burn Leathery skin White Dark brown Charred Minimally painful Dry

38. Body Surface Area Rule of Nines Best used for large surface areas Expedient tool to measure extent of burn Rule of Palms Irregular or splash burns Best used for burns <10% BSA

39. Rule of Nines

40. Rule of Palms

41. Systemic Complications Hypothermia Disruption of skin and its ability to thermoregulate Hypovolemia Shift in proteins, fluids, and electrolytes to the burned tissue Eschar Hard, leathery product of a deep full-thickness burn Dead and denatured skin

42. Systemic Complications Infection Greatest risk of burn is infection Carefully employ Standard Precautions Organ Failure Release of myoglobin Clogs the tubules of the kidneys Special Factors Age and health

43. Systemic Complications Physical Abuse Child or an elderly and infirm adult MOI does not make sense Multiple circular burns Dipping “Stocking” burns Branding © Roy Alson. PhD, MD, FDCEP, FAAEM

44. Assessment of Thermal Burns

45. Assessment of Thermal Burns Skin evaluation tells more about the body’s condition than any other aspect of patient assessment. Must be deliberate, careful, and complete Assign burns the appropriate priority for care.

46. Assessment of Thermal Burns Scene Size-up Do not enter until the scene is made safe Be wary of entering enclosed spaces Stop the burning process Consider the burn mechanism Consider the need for other resources © Glen E. Ellman

47. Assessment of Thermal Burns Initial Assessment Form a general impression of the patient Ensure the airway is patent Look for the signs of any thermal or inhalation injury Provide high-flow, high-concentration oxygen Ensure that the patient’s breathing is adequate

48. Assessment of Thermal Burns Focused and Rapid Trauma Assessment Accurately approximate extent of burn injury: Rule of Nines or Rule of Palms Depth of burn Area of body affected Age of patient affected

49. Severity of Thermal Burns Any partial- or full-thickness burn involving hands, feet, joints, face, or genitalia >30% BSA Partial Thickness Inhalation Injury >10% BSA Full Thickness Critical >2% BSA Full Thickness >50% BSA Superficial <2% BSA Full Thickness <15% BSA Partial Thickness <50% BSA Superficial >15% BSA Partial Thickness Moderate Minor Burn Severity

50. Assessment of Thermal Burns Ongoing Assessment Non-critical: Reassess Q 15 min Critical: Reassess Q 5 min Watch for early signs of hypovolemia and airway problems Be cautious of aggressive fluid therapy Carefully monitor distal circulation and sensation with any circumferential burn

51. Management of Thermal Burns

52. Management of Thermal Burns Includes the prevention of shock, hypothermia, and any further wound contamination Care is divided into two categories: Local and minor burn care Moderate and severe burn care

53. Management of Thermal Burns Local and Minor Burns Local cooling Partial thickness: <15% of BSA Full thickness: <2% BSA Remove clothing Cool or cold water immersion Consider analgesics Morphine sulfate Fentanyl (Sublimaze)

54. Management of Thermal Burns Moderate to Severe Burns Dry sterile dressings Maintain warmth Prevent hypothermia Consider aggressive fluid therapy Burns over IV sites: Place IV in partial-thickness burn site Consider analgesics Morphine sulfate Fentanyl (Sublimaze)

55. Management of Thermal Burns Fluid resuscitation Parkland Formula 4 mL X weight X % burn ½ volume in first 8 hours Second ½ over last 16 hours Where transport time is short (less than 1 hour) 0.25 mL X Patient weight in kg X BSA burned = Amount of fluid

56. Management of Thermal Burns Moderate to Severe Burns Caution for fluid overload Frequent auscultation of breath sounds Consider analgesic for pain Morphine Fentanyl Prevent infection

57. Management of Thermal Burns Inhalation Injury Provide high-flow O 2 by NRB Consider intubation if swelling Consider hyperbaric oxygen therapy

58. Management of Thermal Burns Cyanide exposure Sodium nitrite, amyl nitrite, sodium thiosulfate Forms methemoglobin which binds cyanide Excreted in urine Cyanokit® Binds cyanide by freeing it from the cytochromea3 enzyme Excreted in urine Courtesy © Dey, L.P. © Jeff Forster

59. Assessment and Management of Electrical, Chemical, and Radiation Burns

60. Assessment and Management of Electrical, Chemical, and Radiation Burns Electrical Injuries Safety Turn off power Energized lines act as whips Establish a safety zone Lightning strikes High voltage, high current, high energy Lasts fraction of a second No danger of electrical shock to EMS

61. Electrical Injuries Entrance and exit wounds Remove clothing, jewelry, and leather items Treat any visible injuries ECG monitoring Consider fluid bolus for serious burns . 20 ml/kg Consider sodium bicarbonate 1 mEq/kg Consider mannitol: 10 g

62. Chemical Burns Chemical Burns Scene size-up Hazardous materials team Establish hot, warm, and cold zones Prevent personnel exposure from chemical Specific Chemicals Phenol Dry lime Sodium Riot control agents

63. Chemical Burns Specific Chemicals Phenol Industrial cleaner Alcohol dissolves phenol Irrigate with copious amounts of water Dry Lime Strong corrosive that reacts with water Brush off dry substance Irrigate with copious amounts of cool water Prevents reaction with patient tissues

64. Chemical Burns Sodium Unstable metal Reacts vigorously with water Decontaminate: Brush off dry chemical Cover the wound with oil substance used to store metal

65. Chemical Burns Riot Control Agents Agents CS, CN (Mace), Oleoresin, Capsicum (OC, pepper spray) Irritation of the eyes, mucous membranes, and respiratory tract No permanent damage General signs and symptoms Coughing, gagging, and vomiting Eye pain, tearing, temporary blindness Management Irrigate eyes with normal saline

66. Tar

67. Hot Asphalt

68. Phenol

69. Lime Burn

70. Riot Agents

71. Radiation Burns Radiation Burns Notify hazardous materials team Establish safety zones Hot, warm, and cold Personnel positioned upwind and uphill Use older rescuers for recovery Decontaminate ALL rescuers, equipment, and patients

72. Assessment and Management of Electrical, Chemical, and Radiation Burns Ongoing Assessment Re-evaluate initial assessment Re-evaluate all interventions

73. Summary Introduction to Burn Injuries Anatomy and Physiology of the Skin Pathophysiology of Burns Assessment of Thermal Burns Management of Thermal Burns Assessment and Management of Electrical, Chemical, and Radiation Burns