Too Hot To Handle
Download
Report
Transcript Too Hot To Handle
Burns
Dennis P. McKenna, MD
Albany Medical College
Department of Emergency Medicine
November 21, 2007
J.M. is 32 y/o male worker in a rock mining company
in who was in an enclosed mine exposed to an
equipment explosion. On arrival by medflight he was
under the care of local EMS and screaming in pain and
confused.
VS: BP 115/76 RR 30 O2 sats 92% HR 110
General: Confused, screaming, badly burned
HEENT: Hair burned with soot on face, carbonaceous
sputum, singed eyebrows and nasal hairs, hoarse voice,
fluid coming from R. ear canal
Pulm: Ins/Exp. Wheezing, tachypnea,
CV: Tachycardic, strong femoral and pedal pulses,
radial pulses weak
Abd: Hypoactive bowel sounds
Skin: Second degree burns with blisters and weeping
areas including entire posterior trunk and anterior
chest, deep second degree circumferential burns of
both forearms and hands, mostly first degree burns of
entire face, scalp and posterior head
Neuro: Confused and combative
Patient was rapidly RSI intubated
trauma catheter placed for large volume replacements
based on Parkland Formula
morphine sulfate analgesia with versed for sedation
burns covered with clean sheets
UEs reevaluated for pulses +/- escharotomy
mechanical ventilation reassessed
transport to burn center for complications of
circumferential burns.
Epidemiology
Tissue injury - thermal, electrical, chemical
Can be fatal, disfiguring or incapacitating
3rd largest cause of accidental death
~ 1.25 million burn injuries per year
50,000 hospitalized per year
4500 die per year (3750 from housefires)
Epidemiology
Highest risk are age 18-35
2 ♂ : ♀ risk ratio for both injury and death
Scalds are more likely in 1-5 yr. and elderly
Death rate higher in >65 yr.
Who’s at Risk?
Fire/Combustion
Chemical Exposure
Firefighter
Industrial Worker
Occupant of burning structures
Industrial Worker
Electrical Exposure
Electrician
Electrical Power Distribution Worker
Anatomy and
Physiology of Skin
Skin
Largest body organ. Not a passive organ.
Protects
Temperature regulation
Acts as water tight seal, keeping body fluids in
Sensory organ
Skin
Disruption in the integrity of skin can lead to:
Infection
Inability to maintain normal water balance
Inability to maintain body temperature
Skin
Two layers
Epidermis
Dermis
Epidermis
Outer cells are dead
Act as protection and form water tight seal
Deeper layers divide to produce the
stratum corneum and also contain pigment to
protect against UV radiation
Dermis
Specialized Structures
Tough, elastic connective
tissue
Nerve endings
Blood vessels
Sweat glands
Oil glands - keep skin
waterproof, usually
discharges around hair
shafts
Dermis
Specialized Structures
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
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
Burns
4 phases of burn injury
Emergent phase
Fluid shift phase
Hypermetabolic phase
Resolution phase
Phases
Emergent phase
Response to pain catecholamine release
Fluid shift phase
massive shift of fluid - intravascular extravascular
Phases
Hypermetabolic phase
demand for nutrients repair tissue damage
Resolution phase
scar tissue and remodeling of tissue
Types of Burns
Thermal burn
Skin injury
Inhalation injury
Electrical burn
Lightning
Types of Burns
Chemical burn
Skin injury
Inhalation injury
Mucous membrane
injury
Radiation burn
Burn Classification
An important step in management is to:
determine depth and extent of damage
determine where and how the patient should be
treated
Burn Classifications
1st degree
Involves the epidermis only
Characterized by reddening
Tenderness, pain, & increased warmth
Edema may occur, but no blistering
Burn blanches under pressure
Usually heal in ~ 7 days
Burn Classifications
1st degree
Ex. Sunburn
Burn Classifications
2nd degree (Partial-thickness)
Damage extends through the epidermis and involves
the dermis.
Not enough to interfere with regeneration of the
epithelium
Burn Classifications
2nd degree
Moist, shiny appearance
Salmon pink to red color
Painful
Does not have to blister to be 2nd degree
Usually heal in ~7-21 days
Burn Classifications
Superficial Partial-thickness
Epidermis & superficial (papillary layer) dermis
injured
Often caused by hot water
Very painful
Good perfusion with intact capillaries
Scarring is minimal, heal ~14-21 days
Burn Classifications
Deep Partial-thickness
Extend into deep (reticular layer) dermis
Damage to hair follicles, sweat & sebaceous glands
Usually hot liquids, steam, grease or flame
Exposed dermis is yellow to white, does not blanch
Scarring is common; heal ~3 weeks to 2 mos
May be difficult to distinguish from 3’
Burn Classifications
2nd Degree Burn
(Partial Thickness
Burn)
Burn Classifications
3rd degree
Both epidermis and dermis are destroyed with
burning into SQ fat
Thick, dry appearance
Pearly gray or charred black color
May be minor bleeding
Cannot heal and require grafting
Burn Classifications
3rd degree
Painless - nerve endings are destroyed
Pain is due to intermixing of 2nd degree
Burn Classifications
3rd Degree Burn
(Full Thickness burn)
Body Surface Area Estimation
Rule of Nines
Adult
Palm Rule
Do not include 1st
Body Surface Area Estimation
Peds
For each yr over 1 yr, subtract 1% from head and add
equally to legs
Palm Rule
Burn 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
Burn Severity
Patient age
Less than 10 or greater than 50 have increased
incidence of complication
Burn Severity
Burn configuration
Circumferential burns can cause total occlusion of
circulation due to edema
Restrict ventilation if encircle the chest
Burns on joint area can cause disability due to scar
formation
Minor Burn Criteria
10
20 < 15% BSA
<10% BSA <10 or >50 yr.
30 < 2% BSA
Moderate Burn Criteria
20 15-25% BSA
10-20% BSA <10 or >50 yr.
30 2-10% BSA
Excluding hands, face, feet, or genitalia
Without complicating factors
Critical Burn Criteria
20 > 25% BS
>20% <10 or >50 yr.
30 > 10% BSA
Burns crossing major joints
Circumferential burns
Burns complicated by other
trauma
Underlying health problems
Electrical and deep chemical
burns
Burns with respiratory injury
Hands, face, feet, or genitalia
Thermal Burns
Assessment
Airway and Breathing
Assess for potential
airway involvement
soot or singing involving
mouth, nose, hair, face,
facial hair
coughing, black sputum
enclosed fire environment
Assessment
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
Assessment
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
Assessment
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?
Assessment
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)
Management
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
Management
Airway & Breathing
Not all patients at risk need intubation
Keep in mind long transport times to burn centers if
airway unstable
IV fluid resuscitation can affect airway stability
Management
Other
Assess Burn Surface Area & Associated Injuries
Analgesia
Avoid topical agents except as directed by local burn
centers
e.g. silvadene
Fluid Therapy
Management
Consider Fluid Therapy for
>10% BSA 30
>15% BSA 20
>30-50% BSA 10 with accompanying 20
Management
LR using Parkland Burn Formula
4 mL/kg/% burn over initial 24 hours
1/2 in first 8 hours from time of burn
1/2 over 2nd 16 hours
Peds Management
LR using Parkland Burn Formula
3 mL/kg/% burn in initial 24 hrs plus maintenance
1/2 in first 8 hours from time of burn
1/2 over 2nd 16 hours
Management
Fluid therapy
Objective
HR < 110/minute
Normal sensorium (awake, alert, oriented)
Urine output - 30-50 mL/hour (adult) or
~1 mL/kg/hr (pedi)
Resuscitation formula’s provide estimates,
adjust to individual patient responses
Fluid Management
Is the Parkland Formula Accurate?
Literature indicates that it underestimates
actual fluid needs in isolated cutaneous burns
Is however adequate
Management
Analgesia
Morphine Sulfate
0.05 mg/kg repeated q 10 minutes titrated
to adequate ventilations and blood pressure
May require large doses
Management
Treat Burn Wound
Low priority - After ABC’s and initiation of IV’s
Do not poke/rupture blisters
Management
Treat Burn Wound
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
Circumferential Burns
May require escharotomy by making incisions on the side
of the limb to allow relief of pressure and restore circulation
Incisions made on the radial and ulnar borders of the arm and
forearm, and medial and lateral lower legs
Circumferential burns to chest may cause mechanical restriction to
breathing, requires escharotomy of chest
Escharotomy of chest done by cutting a square on the anterior
chest, incisions made at anterior axillary line from the 2nd rib- 12th
rib vertically, joined by two parallel lines creating a floating box
Escharotomy of Circumferential
Burns
To Transport or Not to
Transport?
Transport Considerations
Appropriate Facility
Burn Center or Not
Factor to consider
Burn Patient Severity Criteria
Critical, Moderate, Minor Burn Criteria
Confounding factors
Transport resources
Transfer Criteria
Partial thickness burns greater than 10% total body
surface area (TBSA)
Burns that involve the face, hands, feet, genitalia,
perineum, or major joints
Third-degree burns in any age group
Electrical burns, including lightning injury
Transfer Criteria
Inhalation injury
Burn injury in patients with preexisting medical
disorders that could:
complicate management,
prolong recovery
affect mortality
Burned children in hospitals without qualified
personnel or equipment for the care of children
Burn injury in patients who will require special social,
emotional, or long-term rehabilitative intervention
Transfer Criteria
Any patients with burns and concomitant trauma in
which the burn injury poses the greatest risk of
morbidity or mortality.
If the trauma poses the greater immediate risk, the
patient may be initially stabilized in a trauma center
before being transferred to a burn unit.
Physician judgment will be necessary in such situations
and should be in concert with the regional medical
control plan and triage protocols.
Inhalation Injury
With improvements in burn treatment, has emerged as
main cause of mortality
½ of ALL fire related deaths
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
Inhalation Injury
Anticipate respiratory problems:
Nasal/Oral mucosa red or dry
Soot in mouth or nose
Coughing up black sputum
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
Inhalation Injury
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
Inhalation Injury
Subglottic 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
Inhalation Injury
Other Considerations
Toxic gas inhalation
Smoke inhalation
Carbon Monoxide poisoning
Thiocyanate poisoning
Thermal burns
Chemical burns
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
Inhalation Injury Management
Indications for
immediate intubation
Full-thickness burns to
face/perioral region
Circumferential neck
burns
Acute respiratory distress
Inhalation Injury Management
Indications for immediate intubation
Progressive hoarseness or air hunger
Respiratory depression or altered metal status
Supraglottic edema and inflammation on
brochoscopy
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
Inhalation Injury Management
Other Considerations
Treat associated inhalation injury/poisoning
Positive pressure ventilation
Hyperbaric chamber (carbon monoxide poisoning)
Transport considerations
Burn Center
Hyperbaric chamber
Smoke Inhalation Injury
A general term that comprises several types of
injuries ( Carbon monoxide poisoning and other
toxic gas exposure such as cyanide, thermal
inhalation injury)
Half of fire-related deaths are due to smoke
inhalation
Doubles the mortality rate for a burn of any
given size
Carbon Monoxide Poisoning
CO has affinity for hemoglobin 200 times that
of oxygen, CO displaces oxygen, patient suffers
tissue hypoxia
Carboxyhemoglobin levels measured as the
%Hgb bound to CO
Percentage of carboxyhemoglobin
and clinical manifestations
% CarboxyHgb
<10%
20%
30%
40-60%
>60%
Clinical Symptoms
No symptoms
Headache, nausea, vomiting, DOE
Confusion, lethargy, visual
disturbances
Coma, seizures, hypotension
Death
Treatment of Carbon Monoxide
Poisoning
Treatment is 100 % oxygen
Half-life of COHb is 4-5 hours on room air, ninety
minutes on 100% oxygen, 20-25 min at 3 atm
hyperbaric oxygen
Indications for hyperbaric therapy
COHb > 25%, >10% if pregnant
Any neurologic symptom other than mild headache
Coma, myocardial ischemia, worsening symptoms despite
oxygen therapy
Blast injuries/ Burns
Blast Injury Physiology
Blasts characterized by release of large quantities
of energy in the form of pressure and heat
Energy is transmitted to surrounding
environment in the form of a blast wave and
blast winds
Energy transfer occurs as the pressure wave
induces oscillation in the medium through
which it travels
Blast Injury Physiology
Blast wave
Begins as a single pulse of increased pressure that rises to
peak levels in milliseconds
Propagated outward radially from the explosion
Blast winds
When rapidly expanding gases from an explosion displace air
causing it to move away at very high velocity
Travel immediately behind the blast wave
Windage can cause disintegration of a body or cause
amputations depending on force
Categories of Blast Injuries
Primary Blast Injury
Results directly form the sudden changes in environmental
pressure caused by the blast wave
Tissues vary in susceptibility to primary blast injury
A.
B.
Homogenous tissues (solid organs) are least at risk because they are
non-compressible, just vibrate as a whole
Gas-filled organs which are compressible and have tissue-gas
interfaces most susceptible. Organs with different densities such as
lungs, bowel, tympanic membranes commonly injured
Explosions in an enclosed space increase the
incidence of primary blast injury because the blast
wave reflects back at the person
Primary Blast InjuryOrgans Involved
Ears- most vulnerable organ, primary complaint
is hearing loss
Perforations TM-usually small and inferior, may
result in blood in external canals
Dislocation of ossicles
Cochlear (inner ear) damage- may result in tinnitis
and vertigo
Primary Blast InjuryOrgans Involved
Lungs- second most vulnerable organ, most severely
affected organ and most likely to present threat to life
Blast wave produces a diffuse lung contusion causing hemorrhage
and edema
Pleural and lung lacerations
May cause alveolar to venous fistulas-allows air to enter pulmonary venous
system, travels to left heart and systemic circulation
Air-embolism- may lodge in lungs, coronary vessels, or CNS and mimic PE,
stroke, or AMI, presents early after explosion, cause of sudden death in
otherwise stable blast injured patient
Pneumothoracis common
Primary Blast InjuryOrgans Involved
GI: Rare injuries, requires high pressures
(close to site of detonation)
Produces hemorrhage into the wall and lumen, also
perforations
Large bowel more often affected because contains
more air
Common clinical symptoms include abd. Pain,
peritonitis, melena
Primary Blast InjuryOrgans Involved
Neuro: Two scenarios
1)
2)
Concussions common- present with amnesia and confusion
Cerebral-air embolism- symptoms of stroke, aphasia, focal
paralysis or hemiplegia, sensory deficits
Other injuries:
Eyes- retinal detachments, IO hemorrhage
Sinuses- ruptured
Categories of Blast Injuries
Secondary blast injury
Tertiary blast injury
Due to blast winds when victim struck by flying
debris
Results from victim being displaced through space
by the blast wind and impacts stationary objects
Type Four blast injury
Result from inhalation of dust and toxic gases,
exposure to radiation, and thermal burns
Management of Blast Injuries
First the scene needs to be secured and declared safe
before approaching
Managed like all trauma with the primary survey
ABCDE, secondary survey, particular attention directed
at respiratory system, maintain airway, oxygen, assess
for thermal injuries, pneumothorax requires needle
decompression if perform BVM or PPV
IV fluids- avoid excessive amounts which worsen
pulmonary function
Management of Blast Injuries
Recognize systemic air emboli- MI, PE, CVA
If symptoms of stroke, put in trendelenberg
position, prevents further air-emboli going to head
Remember that PPV puts blast injured patient at risk
for air-emboli, if intubated or assisted ventilations
keep in back of mind
Preferred therapy is hyperbaric oxygen treatment
Management of Blast Injuries
Remember that explosions in confined spaces
increase risk to victim of blast injuries both from
blast wave and exposures to toxic gases
If symptoms of hearing loss (ruptured TM’s),
good indicator of exposure to significant high
pressures and to be concerned about other
injuries even if initially asymptomatic
Chemical Burns
Chemical Burns
Occur in home, industrial, agriculture, school,
research labs, . . .
First Consideration: Should you be here?
Does the patient need decontamination before
treatment?
Can produce burn, dermatitis, allergic reaction,
thermal injury, or systemic
toxicity
Chemical Burns
Tissue damage determined by:
Strength/concentration of agent
Manner of contact
Quantity of agent
Duration of contact
Mechanism of action
Extent of penetration
Chemical Burns
Acids vs. Alkalis
Alkalis usually produce far more tissue damage
Acids → coagulation necrosis w/ protein precipitation →
eschar formation → limits penetration (except
Hydrofluoric acid)
Alkalis → liquefaction necrosis → loosening of cell
material → allows deeper penetration
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
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
Chemical Burn Management
Dry Chemical Fear
Exothermic reaction with water
Not a reason to delay irrigation with water!!!!
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
Chemical Burn Management
Irrigation should be maintained as a gentle
flow to avoid driving chemical deeper or
splashing
Chemical Burn Management
Remember
Pain control
Fluid management
Specific Chemical Considerations
Lacrimators
First chemical agents used by police/military
Mucous membrane and respiratory tract irritant
Skin sensitizer
Management
Treat respiratory distress
Protect yourself first
Continued irrigation and shower
decontamination
Ocular Burns
Ocular Burns
Chemical burns to eyes are common
Rupture of airbags are new potential for
skin/eye burns
Early = tearing, rubbing, redness, pain,
blepharospasm
Conjunctivitis, clouding of anterior chamber,
pupillary dilatation, & corneal ulceration
Ocular Burns
Ocular Burns
Ocular Burns
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 30
minutes
Nasal Cannula
IV Set
Morgan Lens
Ocular Burns
Remove contact lenses
May trap irritants
Pain control
Topical anesthetics initially
Systemic analgesics
Geriatric Burns
Decreased myocardial reserve
Peripheral vascular disease, diabetes
slow healing
COPD
fluid resuscitation difficulty
increases complications of airway injury
Poor immunological response - Sepsis
% mortality ~= age + % BSA burned