Burn Management - Telco House Bed & Breakfast
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Transcript Burn Management - Telco House Bed & Breakfast
PCP - GORD PATTERSON, ALS-A//V , ACP
Paramedic Burn Care
Primary Care Paramedics:
a critical link allowing serious Burns to
achieve maximally favourable outcomes
Burns must grab your attention
You will be faced with this sometime in
your career
Visual appearance of injury can create
anxiety and scene management challenges
Goal Today is to prepare you to
manage burns
To reinforce an understanding of the
anatomy and the pathophysiology of
burn dynamics.
To enable the student to assess burn
characteristics to thereby provide
appropriate care to the burn victim.
Focus on thermal burns
Burns described
Skin anatomy and function
Respiratory considerations
Fluid shifting
Burn Depth and Zones
Burn Severity
Size estimations
PCP management considerations
Dressing considerations & characteristics
Format – 2.5 hours
Introduction
P/P Presentation
Break out group Burn Classification
Group discussion
P/P Presentation
Break out group Burn size estimation
Group discussion
P/P Presentation
Summary
Fast Facts
Burns are common
Create complex medical challenges
Can be disfiguring and disabling
2nd leading cause of accidental death in
Canada ~ 412 yearly. ~ 40 are children
Prevention Canada)
(Fire
Serious medical issue
~ 73% of deaths are from fires in the
home
Scalding by liquids is the leading cause
of pediatric burn injuries
2,000,000 treatments yearly in Canada
and USA
Burns described
A burn is an injury to tissues caused by
heat, flame, chemicals, radiation,
friction. Burns are classified as
Thermal
Chemical
Electrical
Radiation
Burns characteristics defined by :
Mechanism of injury
Depth of tissue damage
Severity of injury to the patient
Total body surface involved
Injury mechanisms are further
grouped
Scalds
Contact Burns
Fire
Chemical
Electrical
Radiation
Review of skin A & P
Skin is the largest organ of the body
Surface area is approx 1.8 m2 in adults
and .025 m2 in children
It is the most exposed body organ and
prone to burns
It makes up 12 – 15% of body mass
Skin Function Summary
Provides protection against infection
Retains body fluids
Sensory organ and information gatherer
Assists in maintaining body temperature
Protects internal organs
Vitamin D production
Expressive communication
Skin Layers
Epidermis – thinnest layer
Tough protective barrier
Protects internal organs
Sensory aid
Dermis
Contains blood vessels, nerve endings
Prevents water loss (evaporation)
Prevents heat loss
Hypodermis
Subcutaneous tissue primarily fat, connective
tissue, and vascular structure
Skin – Rich in vascular structures
Burns damage vascular structure creating
capillary permeability & fluid shifting
Imagine this over 30% TBSA
Picture source emedicine.com
Fluid shifting occurs in two
stages
Hypovolemic stage ( onset to ~ 36-48
hours)
Diuretic stage ( ~ 48 - 72 hours after
injury)
Hypovolemic Stage
Rapid fluid shifts - from the vascular compartments
into the interstitial spaces
Capillary permeability increases with vasodilation,
cell damage, and histamine release
Fluid loss deep in wounds
-Initially Sodium and H2O
-Protein loss - hypoproteninemia
Hemoconcentration - Hct increases
Low blood volume, oliguria
Hyponatremia - loss of sodium with fluid
Hyperkalemia - damaged cells release K, oliguria
Metabolic acidosis
Diuretic Stage
Capillary membrane integrity returns
Edema fluid shifts back into vessels - blood
volume increases
Increase in renal blood flow - result in
diuresis (unless renal damage)
Hemodilution - low Hct, decreased
potassium as it moves back into the cell or
is excreted in urine with the diuresis
Fluid overload can occur due to increased
intravascular volume
Metabolic acidosis - HCO3 loss in urine,
increase in fat metabolism
Respiratory System
The airway epithelium are susceptible to injury from
inhaled hot gases and can be life threatening
Mucous membranes of the nose, mouth, and
oropharynx
Epiglottis, glottis and vocal cords
Epithelium of the lower respiratory track
Air Flow Obstruction – hypoxia & Hypercarbia
Burn gas by-product such as Carbon Monoxide can
displace oxygen creating hypoxia
Continually monitor pulmonary
status
Airway burns account for the majority of
immediate and delayed deaths from
burns (death up to 24 hours from injury)
Signs of a Respiratory Burn
Red Flags
History of a Closed area heat insult
Productive cough
Dyspnea
Facial burns
Singed nasal hair
Sooty sputum
Horse voice
Primary care of any burns begins
with:
Classification of burn depth
Estimation of burn size
Classification of burn depth is
determined by structures injured
Increasing severity
Epidermis
Dermis
Hypodermis
& deeper
Muscle,
tendons and
bone
Traditional Classification
1st degree
Epiderminal layer, red, painful
2nd degree
Epiderminal layer and some dermis, blisters,
painful
3rd degree
Full thickness epidermis, all dermis including
hypodermis
4th degree
Full thickness including hypodermis and deep
facia
New Classification
Superficial
Superficial Partial Thickness
Deep Partial Thickness
Full Thickness
Fourth Degree
Superficial Burns
Epidermis
Hypodermis &
deeper
Muscle, tendons and
bone
Involve only the epidermal layer of skin.
Dermis
Red
Dry
Painful
Blanches
Heals spontaneously
Superficial
Superficial Partial Thickness
Epidermis
Dermis
Hypodermis &
deeper
Muscle, tendons and
bone
Involve entire epidermis and superficial
portions of the dermis
Painful , red and weeping usually from
blisters
Blanches with pressure
Generally heals spontaneously
Superficial Partial Thickness
Deep Partial Thickness
Epidermis
Dermis
Hypodermis &
deeper
Muscle, tendons and
bone
Involve entire epidermis
Extends into deeper dermis damaging
glandular tissue and hair follicles
Blisters
Wet or waxy dry
Variable colour from patchy white to red
May heal spontaneously
Deep Partial Thickness
Full Thickness Burns
Epidermis
Dermis
Hypodermis &
deeper
Muscle, tendons and
bone
Includes destruction of epidermis, the
entire dermis
Damage to the hypodermis
Waxy white to leathery grey to charred and
black
Less painful
May require skin grafting
Full Thickness Burn
Fourth Degree Burns
Epidermis
Dermis
Hypodermis &
deeper
Muscle, tendons and
bone
Includes destruction of epidermis, the
entire dermis and the hypodermis
Destruction of the hypodermis
Deep facia, variable colour, leathery, bone
exposure
Less painful
Requires skin grafting
Fourth degree burn
Break Out Group Pictures
Four Groups
15 minutes
Choose speaker to discuss burn
Object:
Assess Burn Depth
Burn classification
Distinguishing features
Skin structures involved
Notions
Burns are generally have a combination
of varying degrees and zones of burn
classification in the same injury
All burns are painful
All victims are frightened
Burns have a “Wow Factor” and an
unforgettable aroma
A single burn can be made up of
combination of classifications
Cell damages occurs in varying
degrees creating Burn Zones
Hyperemia
Zone
Stasis
Zone
Coagulation
Zone
• Minimal cell damage and
vascular engorgement
• Viable Injury
• Necrosis
Identify tissue viability
Critical burn body areas are:
Respiratory tract
Face, eyes
Hands & feet joint areas
Perineum
Circumferential burns
Circumferential burns constrict
circulation
How does this occur
Encircling damaged skin (eschar) looses
elasticity and constricts damaged
tissues by compartmentalizing fluid
shifting in underlying tissues increasing
interstitial pressures that compress
vascular structures and nerves
Tissue hypoxia
Further tissue & cell damage
Fixes: Escharotomy or Fasiotomy
Is this patient sick?
Severity of injury is dependent on
Size of burn or Total Body Surface Area
injured (TBSA)
Classification or depth of injury
Critical area involvement
Age
Prior health status
Location of burn
Associated injuries
Accurate burn size estimation is
essential to determine severity
Rule of Nines
Adult:
Head 9%
Arms 9%(each)
Torso (front/back)18%
Legs 18%
Perineum 1%
Child:
Head18%
Arms 9% (each)
Torso (front/back) 18%
Legs14% (each)
Perineum1%
Palmer Method
The area of the patient’s hand size including
the fingers is approximately 1% TBSA
Rule of Nines
Severity is further described as:
Major
Moderate
Minor
Minor Burn
Minor
<10 percent TBSA burn in adult
<5 percent TBSA burn in young or old
<2 percent full thickness burn
Moderate Burn
Moderate
10 to 20 percent TBSA burn in adult
5 to 10 percent TBSA burn in young or old
2 to 5 percent full-thickness burn
High-voltage injury
Suspected inhalation injury
Circumferential burn
Concomitant medical problem predisposing
the patient to infection (e.g., diabetes, sickle
cell disease)
Major Burn
Major
>20 percent TBSA burn in adult
>10 percent TBSA burn in young or old
>5 percent full-thickness burn
High-voltage burn
Known inhalation injury
Any significant burn to face, eyes, ears, genitalia
or joints
Significant associated injuries (e.g., fracture,
other major trauma)
Break Out Group Pictures
Four Groups
15 minutes
Choose speaker to discuss burn
Object:
Assess Burn Size
TBSA
Severity
Structures involved
Burn Mortality
Management is focused to prevent
mortality and morbidly
Death from burns
Initial 24 hours:
respiratory burn
hypovolemic shock
After 24 hours:
infection
kidney failure
Primary Burn Management
Scene Safe
ABC’s
Expose and examine
Remove constricting jewellery/watches
Initiate cooling (Thermal)
Flush chemicals off (Chemical)
High flow oxygen
Calculate TBSA
Evaluate injury depth
Evaluate injury severity
Burn Priorities
Timely transport!
Prepare for urgent A/W interventions
BV Mask passive assistance
ALS backup
Infection control (Damaged tissue & vascular bed
ideal conditions for bacteria growth)
Cool then dress wounds dry sterile
Pain control as appropriate
Prevent hypotension/hypothermia
Appropriate hospital destination
Hospital communication
Thermal burns
PCP management considerations:
Ensure scene safety
Remove the patient from the source of the burn
ABC’s
High flow oxygen
Assess for associated injuries
Remove clothing and jewelry from burn sites
Cool soaks with sterile water
< 20% up to 30 minutes
> 20% up to 10 minutes – Major burns no more than 10 minutes
Cover with dry sterile dressings or a clean sheet
Watch for and prevent hypothermia
Pain management – Entonox (no inhalation injury)
Venous access (large bore) – 500 ml NS bolus’ PRN up to
2 Litres to BP above 90 mmHg
Chemical Burn
PCP management considerations:
Paramedic safety - PPE
Brush off dry chemical
Flush with copious irrigation for 20
minutes
Prevent hypothermia
Pain management – Entonox
Venous access
Electrical burns
PCP management considerations:
Ensure scene is electrically safe
Then remove the patient from the electrical
source
ABC’s· High flow oxygen· Assess and treat
for associated injuries
Moist sterile dressing to burn
Pain management – Entonox
Venous access (large bore) – 500 ml NS
bolus’ PRN up to 2 Litres to BP above 90
mmHg
Cool Soak Dressing management
Skin destruction removes the body's
primary insulation
Heat loss can be rapid, especially in
children
Cool with tepid isotonic solutions
Cool Major burns no more
than 10 minutes
Risk of Hypothermia
Ideal dressing characteristics
Sterile
Large enough to cover injury
Absorbent fluid controlling
Lint free
Thermal insulation
Non adhering
Non constricting
Allow expansion of underlying tissues
Important emphasis
Create a sterile field for dressings
Dressing must be loosely applied to protect
the injury from infection and control
drainage
Non constricting
An inappropriately applied dressing can
increase extent of injury by:
Compressing injury
○ Restricting blood flow
○ Compartment syndrome
○ Tissue hypoxia
○ Anaerobic metabolism and acidosis
Summary
Do:
Assess the A/W repeatedly, repeatedly
Stop the burning process
Oxygenate
Keep the patient warm
Apply loose dry sterile dressings
Give IV fluids
Consider ALS
Don’t:
Don’t pull stuck clothing off the burn
Don’t put on ointment
Don’t drown your patient
Don’t panic
Thank you
References & Photos
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Emedicine.com
Tabers Medical Dictionary
BurnSurgery.org
HealthCentral.com
Adam Corporation
Wikipedia.org
Emcert.com
BCAS Protocol Guidelines
Fastlane.com
Healthcentral.com