Burns

BurnsBurns

SectionsSections 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

1.25-2 million Americans treated for burns annually 50,000 require hospitalization 3-5% considered life threatening 2nd leading cause of death for children <12 Half of all tap-water burns occur to children <5

Greatest risk Very young & very old Infirm Firefighters Metal smelters Chemical workers

Introduction to Introduction to Burn InjuriesBurn Injuries

Layers Epidermis Dermis Subcutaneous Underlying

Structures Fascia Nerves Tendons Ligaments Muscles Organs

Anatomy & Anatomy & Physiology Physiology of the Skinof 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

Anatomy & Anatomy & Physiology Physiology of the Skinof the Skin

Pathophysiology of Pathophysiology of BurnsBurns Types of Burns

Thermal Electrical Chemical Radiation

Thermal BurnsThermal Burns Heat changes the molecular

structure of tissue Denaturing (of proteins)

Extent of burn damage depends on Temperature of agent Concentration of heat Duration of contact

Thermal BurnsThermal Burns Jackson’s Theory of Thermal Wounds

Zone of Coagulation Area in a burn nearest the heat source that suffers

the most damage as evidenced by clotted blood and thrombosed blood vessels

Zone of Stasis Area surrounding zone of coagulation

characterized by decreased blood flow. Zone of Hyperemia

Peripheral area around burn that has an increased blood flow.

Jackson’s Theory of Jackson’s Theory of Thermal WoundsThermal Wounds

Zone of Hyperemia

Zone of Stasis

Zone of Coagulation

Body’s Response to Body’s Response to BurnsBurns Emergent Phase (Stage 1)

Pain response Catecholamine release Tachycardia, Tachypnea, Mild Hypertension, Mild

Anxiety Fluid Shift Phase (Stage 2)

Length 18-24 hours Begins after Emergent Phase

Reaches peak in 6-8 hours Damaged cells initiate inflammatory response

Increased blood flow to cells Shift of fluid from intravascular to extravascular space

• MASSIVE EDEMA• “Leaky Capillaries

Body’s Response to Body’s Response to BurnsBurns Hypermetabolic Phase (Stage 3)

Last for days to weeks Large increase in the body’s need for

nutrients as it repairs itself Resolution Phase (Stage 4)

Scar formation General rehabilitation and progression to

normal function

Electrical BurnsElectrical Burns Terminology

Voltage Difference of electrical potential between two

points Different concentrations of electrons

Amperes Strength of electrical current

Resistance (Ohms) Opposition to electrical flow

Electrical BurnsElectrical Burns Ohm’s Law

V: VoltageR: ResistanceI: Current

Based on electron flow thru Tungsten Emit more light the more current passed thru

IRV RVI

Electrical BurnsElectrical Burns Joule’s Law

P: Power

Skin is resistant to electrical flow Greater the current the greater the flow thru

the body and greater the release of heat

RIP 2

Electrical BurnsElectrical 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

Electrical BurnsElectrical Burns Electrical Current Flow

Tissue of Less Resistance Blood vessels Nerve

Tissue of Greater Resistance Muscle Bone

Results in Serious vascular and nervous injury Immobilization of muscles Flash burns

Chemical BurnsChemical Burns Chemical destroys 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

Radiation InjuryRadiation Injury Radiation

Transmission of energy Nuclear Energy Ultraviolet light Visible Light Heat Sound X-Rays

Radioactive Substance Emits ionizing radiation Radionuclide or Radioisotope

Radiation InjuryRadiation InjuryBasic PhysicsBasic Physics

Protons Positive charged particles

Neutrons Equal in mass to protons No electrical charge

Electrons Minute electrically charged particles When emitted from radioactive

substances are termed Beta Particles(continued)

Radiation InjuryRadiation InjuryBasic PhysicsBasic Physics

Isotopes Atoms with unstable nuclear composition

Ionizing Radiation

Half-life Time required for half the nuclei to lose

activity through decay

Radiation InjuryRadiation InjuryRadioactive Radioactive SubstancesSubstances

Alpha Particles Slow moving Low-energy Stopped by clothing

and paper Penetrate a few cell

layers on skin Minor external hazard HARMFUL if ingested

Beta Particles Smaller than Alpha Higher energy than

alpha Stopped by

aluminum or similar materials

Less local damage than alpha

HARMFUL if inhaled or ingested

Radiation InjuryRadiation InjuryRadioactive Radioactive SubstancesSubstances Gamma Rays

Highly energized Penetrate deeper than Alpha

or Beta EXTREMELY DANGEROUS Penetrate thick shielding Pass entirely thru clothing,

and body Extensive cell damage

Indirect Damage Cause internal tissue to emit

Alpha and Beta particles LEAD SHIELDING

Neutrons Most Penetrating

than other radiation 3-10 times greater

penetration than Gamma

Less internal hazard when ingested than Alpha or Beta

Direct tissue damage Only present in

Nuclear Reactor Core

Radiation InjuryRadiation InjuryEffects on BodyEffects on Body

Geiger Counter needed to detect R/hr: Milliroentgens per hour

1,000mR = 1R

RAD Radiation absorbed dose of

local tissue REM

Roentgen equivalent in man Injury to irradiated part of

organism RAD=REM for all purposes

Alters body’s cell DNA

Cumulative damage over lifetime exposure

Decreased WBC’s Acute

Effects in minutes-weeks

Long-Term Effects years or decades

later

Radiation Injury: Radiation Injury: SafetySafety Clean

Accident Exposed to

radiation Not contaminated

by products Properly

decontaminated Little danger to

personnel

Dirty Accident Assoc with Fire at

scene of rad. Accident

Trained Decon. Personnel

DISTANCE

SHEILDING

TIME

Park upwind Notify Radiation Response or Haz-

Mat Response Team Look for radioactive placards Measure radioactivity Decontaminate patients before care Routine medical care (ABC’s, etc)

Radiation InjuryRadiation InjuryManagementManagement

Inhalation InjuryInhalation Injury Toxic Inhalation

Synthetic resin combustion Cyanide & Hydrogen Sulfide Systemic poisoning More frequent than thermal inhalation burn

Carbon Monoxide Poisoning Colorless, odorless, tasteless gas Byproduct of incomplete combustion of carbon

products Suspect with faulty heating unit

200x greater affinity for hemoglobin than oxygen Hypoxemia & Hypercarbia

Inhalation InjuryInhalation 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 Risk Factors

Standing in the burn environment Screaming or yelling in the burn environment Trapped in a closed burn environment

Symptoms Stridor or “Crowing” inspiratory sounds Singed facial and nasal hair Black sputum or facial burns Progressive respiratory obstruction and arrest due to

swelling

Depth of BurnDepth of Burn Superficial Burn Partial Thickness Burn Full Thickness Burn

Burn DepthBurn Depth Superficial

Burn:1st Degree Burn Signs &

Symptoms Reddened skin Pain at burn site Involves only

epidermis

Burn DepthBurn Depth Partial-

Thickness Burn: 2nd Degree Burn Signs &

Symptoms Intense pain White to red skin Blisters Involves

epidermis & dermis

Burn DepthBurn Depth Full-Thickness

Burn: 3rd Degree Burn Signs & Symptoms

Dry, leathery skin (white, dark brown, or charred)

Loss of sensation (little pain)

All dermal layers/tissue may be involved

Body Surface AreaBody Surface Area Rule of Nines

Best used for large surface areas Expedient tool to measure extent of burn

Rule of Palms Best used for burns < 10% BSA

Rules of NinesRules of Nines

18

4 .5

9

1

9

4.5

184.

5 4 .59 9

4.5

9 94 .5

7

4 .5

7

4 .5

7

18 181

Rule of PalmsRule of Palms A burn equivalent to the size of

the patient’s hand is equal to 1% body surface area (BSA)

Systemic Systemic ComplicationsComplications Hypothermia

Disruption of skin and its ability to thermoregulate

Hypovolemia Shift in proteins, fluids, and electrolytes to the

burned tissue General electrolyte imbalance

Eschar Hard, leathery product of a deep full thickness burn Dead and denatured skin

Systemic Systemic ComplicationsComplications Infection

Greatest risk of burn is infection Organ Failure

Release of myoglobin Special Factors

Age & Health Physical Abuse

Elderly, Infirm or Young

Scene Size-up Fire Department

SCBA and protective clothing

Initial Assessment ABC’s MUST be intact

Consider ET or RSI Rapid evacuation of patient if scene is

unstable

Assessment of Assessment of Thermal BurnsThermal 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 effected

• Any burn to the face, hands, feet, joints or genitalia is considered a serious burn

“Ringing” burns Age of patient affected


Pain Changes in skin

condition at affected site

Adventitious sounds Blisters Sloughing of skin Hoarseness Dysphagia Dysphasia

Assessment of Thermal Assessment of Thermal BurnsBurns

General Signs & General Signs & SymptomsSymptoms

Burnt hair Edema Paresthesia Hemorrhage Other soft tissue

injury Musculoskeletal

injury Dyspnea Chest pain

Assessment of Thermal Assessment of Thermal BurnsBurns

Any partial or full thickness burn involving hands, feet, joints,face, or genitalia

>30% BSAPartial Thickness

Inhalation Injury>10% BSAFull Thickness

Critical

>2% BSAFull Thickness

>50% BSASuperficial

<2% BSAFull Thickness<15% BSAPartial Thickness<50% BSASuperficial

>15% BSAPartial Thickness

Moderate

Minor

Burn SeverityBurn Severity

Ongoing Assessment Non-critical: Reassess Q 15 min Critical: Reassess Q 5 min

Burn Center Care


Local & Minor Burns Local cooling

Partial thickness: <15% of BSA Full thickness: <2% BSA

Remove clothing Cool or Cold water immersion Consider analgesics

Management of Management of Thermal BurnsThermal Burns

Moderate to Severe Burns Dry sterile dressings

Partial thickness: >15% BSA Full thickness: >5% BSA

Maintain warmth Prevent hypothermia

Consider aggressive fluid therapy Moderate to severe burns

Burns over IV sites Place IV in partial thickness burn site.


Parkland Burn Formula

4 mL x Pt wt in kg x % BSA = Amt of fluid

Pt should receive ½ of this amount in first 8 hrs. Remainder in 16 hrs Consider 1 hour dose

0.5ml x Pt wt in kg x % BSA = Amt of fluid


Moderate to Severe Burns Caution for fluid overload

Frequent auscultation of breath sounds Consider analgesic for pain

Morphine Nubain

Prevent infection


Inhalation Injury Provide high-flow O2 by NRB Consider intubation if swelling Consider hyperbaric oxygen therapy Cyanide Exposure

Sodium Nitrite, Amyl Nitrite, Sodium Thiosulfate• Forms methemoglobin binds to cyanide• Non-toxic substance secreted in urine

Inhale 1 ampule of Amyl Nitrite 300 mg Sodium Nitrite over 2-4 minutes 12.5 gm of Sodium Thiosulfate


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

Assessment & Management Assessment & Management of Electrical, Chemical & of Electrical, Chemical &

Radiation BurnsRadiation Burns

Assess patient Entrance & Exit wounds Remove clothing, jewelry, and leather items Treat any visible injuries

• Thermal burns ECG monitoring

• Bradycardia, Tachycardia, VF or Asystole ACLS Protocols

• Treat cardiac & respiratory arrest• Aggressive airway, ventilation, and circulatory management.

Consider Fluid bolus for serious burns• 20 ml/kg

Consider Sodium Bicarbonate: 1 mEq/kg Consider Mannitol: 10 g



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



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



Sodium Unstable metal Reacts vigorously with water

Releases • Extreme heat• Hydrogen gas• Ignition

Decontaminate: Brush off dry chemical Cover the wound with oil substance



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 & Symptoms

Coughing, gagging, and vomiting Eye pain, tearing, temporary blindness

Management Irrigate eyes with normal saline



Radiation Burns Notify Hazardous Materials Team Establish Safety Zones

Hot, Warm, & Cold Personnel positioned Upwind and Uphill Use older rescuers for recovery Decontaminate ALL rescuers, equipment

and patients



Radiation Injury Whole Body Radiation Injury Whole Body ExposureExposure

RAD vs. Body EffectsRAD vs. Body Effects

Burning sensation in minutes, N/V in 10 minConfusion ataxia, Watery Diarrhea in 2 hrs100% Fatal in short time

1,000+

N/V, Diarrhea in hours100% Fatal within two weeks with Med. Care

600-1,000

N/V, Diarrhea, Weakness & Fatigue in Hours50% Fatal within 6 weeks without Med Care200-600

N/V, Diarrhea, Anxiety, Tachycardia125-200

Anorexia, N/V and Fatigue in 2 days75-125

Asymptomatic, WBC changes50-75Asymptomatic5-25

Effect(RAD)

Radiation InjuryRadiation InjuryLocal Exposure (RAD) vs Local Local Exposure (RAD) vs Local

EffectEffect

Permanent destruction of exposed tissue50,000

Chronic ulcer, risk of cancer5,000

Atrophy, vascular lesion, altered pigment2,500

Asymptomatic (usually), Altered function of exposed area500

Asymptomatic50

Effect(RAD)

Ongoing assessment Re-evaluate initial assessment Re-evaluate all interventions



Burns

Documents

assessment

pt wt

copious amounts

chemical amp

burns

rad

management

diarrhea