Burns

CMSgt John Jonckers Superintendent 141st MDG Medical SMEE - Thailand

1. BURNS
CMSgt John Jonckers
Superintendent 141
st
MDG
Medical SMEE - Thailand

2. 2
Anatomy of Skin
lLargest body organ
lMore than just a passive
covering

3. 3
Skin Functions
lSensation
lProtection
lTemperature regulation
lFluid retention

4. 4
Anatomy
lTwo layers
•Epidermis
•Dermis

5. 5
Epidermis
lOuter layer
lTop (stratum corneum) consists
of dead, hardened cells
lLower epidermal layers form
stratum corneum and contain
protective pigments

6. 6
Dermis
lElastic connective tissue
lContains specialized structures
•Nerve endings
•Blood vessels
•Sweat glands
•Sebaceous (oil) glands
•Hair follicles

7. 7
Burn Epidemiology
l2,500,000/year
l100,000 hospitalized
l12,000 deaths
Third leading cause of trauma deaths
in the US.

8. 8
Pathophysiology
lLoss of fluids
lInability to maintain body
temperature
lInfection

9. 9
Critical Factors
lDepth
lExtent

10. 10
Burn Depth
lFirst Degree (Superficial)
•Involves only epidermis
•Red
•Painful
•Tender
•Blanches under pressure
•Possible swelling, no
blisters
•Heal in ~7 days

11. 11
Burn Depth
lSecond Degree
(Partial Thickness)
•Extends through
epidermis into dermis
•Salmon (dark) pink
•Moist, shiny
•Very Painful
•Blisters usually present
•Heal in ~7 to 21 days

12. 12
Burn Depth
lThird Degree (Full
Thickness)
•Through epidermis, dermis
into underlying structures
•Thick, dry, leather feeling
•Pearly gray or charred
black
•May bleed / ooze from
vessel damage
•Painless
•Require grafting

13. 13
Burn Depth
lOften cannot be accurately
determined in acute stage
lInfection may convert to higher
degree due to tissue damage
lWhen in doubt, over-estimate

14. Burn Extent
Rule of Nines

15. 15
Burn Extent
lAdult Rule of Nines
9
9
9
18
18
1
18, Front
18, Back

16. 16
Burn Extent
lPediatric Rule of Nines
18
9
9
13.5
13.5
1
18, Front
18, Back
For each year over 1
year of age, subtract
1% from head,
add equally to legs.

17. 17
Burn Extent
lRule of Palm
•Patient’s palm
equals 1% of
his body
surface area

18. 18
Burn Severity
lBased on
•Depth
•Extent
•Location
•Cause
•Patient Age
•Associated Factors

19. 19
Critical Burns
l3rd Degree >10% BSA
l2nd Degree > 25% BSA (20% pediatric)
lFace, Feet, Hands, Perineum
lAirway/Respiratory Involvement
lAssociated Trauma
lAssociated Medical Disease
lElectrical Burns
lDeep Chemical Burns

20. 20
Moderate Burns
l3rd Degree 2 to 10%
l2nd Degree 15 to 25% (10 to
20% pediatric)

21. 21
Minor Burns
l3rd Degree <2%
l2nd Degree <15% (<10%
pediatric)

22. 22
Associated Factors
lPatient Age
•< 5 years old
•> 55 years old
lBurn Location
•Circumferential burns of chest,
extremities

23. MANAGEMENT of Burned
Patients

24. 24
Stop Burning Process
lRemove patient from source of
injury
lRemove clothing unless stuck
to burn
lCut around clothing stuck to
burn, leave in place

25. 25
Assess
Airway/Breathing
lStart oxygen if:
•Moderate or critical burn
•Decreased level of consciousness
•Signs of respiratory involvement
•Burn occurred in closed space
•History of CO or smoke exposure
lAssist ventilations as needed

26. 26
Assess Circulation
lCheck for shock signs /symptoms
Early shock seldom results from effects of
burn itself.
Early shock = Another injury until proven
otherwise

27. 27
Obtain History
lHow long ago?
lWhat has been done for pt.?
lWhat caused burn?
lBurned while in confined space?
lLoss of consciousness?
lAllergies/medications?
lPast medical history?

28. 28
Rapid Physical Exam
lCheck for other injuries
lRapidly estimate burned,
unburned areas
lRemove constricting bands

29. 29
Treat Burn Wound
lCover with DRY, CLEAN SHEETS
lDo NOT rupture blisters
lDo NOT put goo, butter, oil or
grease of any kind on the burn

30. 30
IV Fluid Replacement
Parkland formula
4cc X KG X %(2
nd
/3
rd
burn) = total
cc’s to be infused
½ will be given in 1
st
8 hours,
from time of burn.
¼ will be given in the 2
nd
8 hours
¼ will be given in the 3
rd
8 hours

31. 31
Special Considerations
lPediatrics
lGeriatrics
lLocation of burn

32. 32
Pediatrics
lThin skin, increased severity
lLarge surface to volume ratio
lPoor immune response
lSmall airways, limited
respiratory reserve capacity
lConsider possibility of abuse

33. 33
Geriatrics
lThin skin, poorly circulation
lUnderlying disease processes
•Pulmonary
•Peripheral vascular
lDecreased cardiac reserve
lDecreased immune response

34. Inhalation Injury

35. 35
Problems
lHypoxia
lCarbon monoxide toxicity
lUpper airway burn
lLower airway burn

36. 36
Carbon Monoxide
lProduct of incomplete combustion
lColorless, odorless, tasteless
lBinds to hemoglobin 200x stronger
than oxygen
lHeadache, nausea, vomiting,
“roaring” in ears

37. 37
Upper Airway Burn
lTrue Thermal Burn
lDanger Signs
•Neck, face burns
•Singing of nasal hairs, eyebrows
•Tachypnea, hoarseness, drooling
•Red, dry oral/nasal mucosa

38. 38
Lower Airway Burn
lChemical Injury
lDanger Signs
•Loss of consciousness
•Burned in a closed space
•Tachypnea (+/-)
•Cough
•Rales, wheezes, rhonchi
•Carbonaceous sputum

39. Chemical Burns

40. 40
Concerns
lDamage to skin
lAbsorption of chemical; systemic
toxic effects
lAvoiding personal exposure and
exposure to crew / hospital.

41. 41
Management
lRemove chemical from skin
lLiquids
•Flush with water
lDry chemicals
•Brush away
•Flush what remains with water

42. 42
Chemical in Eyes
lFlush with copious amounts of
NS or Ringers
lDon’t put other chemicals in eye
lFlush out contacts

43. Electrical Burns

44. 44
Considerations
lIntensity of current
lDuration of contact
lKind of current (AC or DC)
lWidth of current path
lTypes of tissues exposed
(resistance)

45. Voltage
Voltage Does Not Kill
Current Kills

46. 46
Electrical Burns
lConductive injuries
•“Tip of Iceberg”
•Entrance/exit wounds may be small
•Massive tissue damage between
entrance/exit

47. 47
Other Complications
lCardiac arrest/arrhythmias
lRespiratory arrest
lSpinal fractures
lLong bone fractures

48. 48
Management
lMake sure current is off!
lCheck ABCs
lAssess carefully for other injuries
lPatient needs hospital evaluation,
observation

49. 49
Burn References
Mosby’s “Paramedic Textbook”
Revised Second Edition - 2001
Chapter 21 Burns
Mick J. Sanders
Flight Nursing - Principles &
Practice – 1991
Genell Lee