Transcript Too Hot To Handle

Burns
Dennis P. McKenna, MD
Albany Medical College
Department of Emergency Medicine
November 21, 2007
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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
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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
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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
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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
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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?
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Fire/Combustion
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Chemical Exposure
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Firefighter
Industrial Worker
Occupant of burning structures
Industrial Worker
Electrical Exposure
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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
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Skin
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Disruption in the integrity of skin can lead to:
Infection
 Inability to maintain normal water balance
 Inability to maintain body temperature
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Skin
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Two layers
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Epidermis
Dermis
Epidermis
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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
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Specialized Structures
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Tough, elastic connective
tissue
Nerve endings
Blood vessels
Sweat glands
Oil glands - keep skin
waterproof, usually
discharges around hair
shafts
Dermis
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Specialized Structures
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Hair follicles - produce hair from hair root or papilla
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Each follicle has a small muscle (arrectus pillorum) which
can pull the hair upright and cause goose flesh
Burn Injuries
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Potential complications
Fluid and Electrolyte loss  Hypovolemia
 Hypothermia, Infection, Acidosis
  catecholamine release, vasoconstriction
 Renal or hepatic failure
 Formation of eschar
 Complications of circumferential burn
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Burns
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4 phases of burn injury
Emergent phase
 Fluid shift phase
 Hypermetabolic phase
 Resolution phase
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Phases
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Emergent phase
 Response to pain  catecholamine release
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Fluid shift phase
 massive shift of fluid - intravascular  extravascular
Phases
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Hypermetabolic phase
  demand for nutrients  repair tissue damage
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Resolution phase
 scar tissue and remodeling of tissue
Types of Burns
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Thermal burn
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Skin injury
Inhalation injury
Electrical burn
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Lightning
Types of Burns
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Chemical burn
 Skin injury
 Inhalation injury
 Mucous membrane
injury
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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
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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
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Burn Classifications
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1st degree
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Ex. Sunburn
Burn Classifications
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2nd degree (Partial-thickness)
Damage extends through the epidermis and involves
the dermis.
 Not enough to interfere with regeneration of the
epithelium
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Burn Classifications
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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
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Burn Classifications
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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
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Burn Classifications
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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’
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Burn Classifications
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2nd Degree Burn
(Partial Thickness
Burn)
Burn Classifications
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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
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Burn Classifications
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3rd degree
 Painless - nerve endings are destroyed
 Pain is due to intermixing of 2nd degree
Burn Classifications
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3rd Degree Burn
(Full Thickness burn)
Body Surface Area Estimation
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Rule of Nines
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Adult
Palm Rule
Do not include 1st
Body Surface Area Estimation
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Peds
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For each yr over 1 yr, subtract 1% from head and add
equally to legs
Palm Rule
Burn Severity
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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
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Patient age
 Less than 10 or greater than 50 have increased
incidence of complication
Burn Severity
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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
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Minor Burn Criteria
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10
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20 < 15% BSA
<10% BSA <10 or >50 yr.
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30 < 2% BSA
Moderate Burn Criteria
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20 15-25% BSA
10-20% BSA <10 or >50 yr.
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30 2-10% BSA
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Excluding hands, face, feet, or genitalia
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Without complicating factors
Critical Burn Criteria
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20 > 25% BS
>20% <10 or >50 yr.
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30 > 10% BSA
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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
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Airway and Breathing
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Assess for potential
airway involvement
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soot or singing involving
mouth, nose, hair, face,
facial hair
coughing, black sputum
enclosed fire environment
Assessment
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Airway and Breathing (cont)
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Respiratory rates are unreliable due to toxic
combustion product’s
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May cause depressant effects
Be prepared to intubate early if patient has inhalation
injuries
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Prep early for RSI
Assessment
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Circulatory Status
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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
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Pertinent History
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How long ago?
What care has been given?
What burned with?
Burned in closed space?
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Products of combustion present?
How long exposed?
Loss of consciousness?
Past medical history?
Assessment
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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)
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Management
Assist ventilations as needed
 100% oxygen via NRB if:
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Moderate or critical burn
 Patient unconscious
 Signs of possible airway burn/inhalation injury
 History of exposure to carbon monoxide or smoke
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Management
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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
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Management
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Other
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Assess Burn Surface Area & Associated Injuries
 Analgesia
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Avoid topical agents except as directed by local burn
centers
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e.g. silvadene
Fluid Therapy
Management
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Consider Fluid Therapy for
>10% BSA 30
 >15% BSA 20
 >30-50% BSA 10 with accompanying 20
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Management
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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
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Peds Management
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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
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Management
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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
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Is the Parkland Formula Accurate?
 Literature indicates that it underestimates
actual fluid needs in isolated cutaneous burns
 Is however adequate
Management
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Analgesia
 Morphine Sulfate
 0.05 mg/kg repeated q 10 minutes titrated
to adequate ventilations and blood pressure
 May require large doses
Management
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Treat Burn Wound
 Low priority - After ABC’s and initiation of IV’s
 Do not poke/rupture blisters
Management
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Treat Burn Wound
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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
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No “Goo” on burn unless directed by burn center
Circumferential Burns
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May require escharotomy by making incisions on the side
of the limb to allow relief of pressure and restore circulation
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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?
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Transport Considerations
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Appropriate Facility
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Burn Center or Not
Factor to consider
Burn Patient Severity Criteria
 Critical, Moderate, Minor Burn Criteria
 Confounding factors
 Transport resources
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Transfer Criteria
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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
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Inhalation injury
Burn injury in patients with preexisting medical
disorders that could:
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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
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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
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With improvements in burn treatment, has emerged as
main cause of mortality
½ of ALL fire related deaths
Inhalation Injury
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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
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Anticipate respiratory problems:
Nasal/Oral mucosa red or dry
 Soot in mouth or nose
 Coughing up black sputum
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Inhalation Injury
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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
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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
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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
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Other Considerations
Toxic gas inhalation
 Smoke inhalation
 Carbon Monoxide poisoning
 Thiocyanate poisoning
 Thermal burns
 Chemical burns
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Inhalation Injury Management
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Airway, Oxygenation and Ventilation
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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
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Indications for
immediate intubation
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Full-thickness burns to
face/perioral region
Circumferential neck
burns
Acute respiratory distress
Inhalation Injury Management
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Indications for immediate intubation
Progressive hoarseness or air hunger
 Respiratory depression or altered metal status
 Supraglottic edema and inflammation on
brochoscopy
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Inhalation Injury Management
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Circulation
Treat for Shock (rare)
 IV Access
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LR/NS large bore, multiple IVs
 Titrate fluids to maintain systolic BP and perfusion
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Avoid MAST
Inhalation Injury Management
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Other Considerations
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Treat associated inhalation injury/poisoning
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Positive pressure ventilation
Hyperbaric chamber (carbon monoxide poisoning)
Transport considerations
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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
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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
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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
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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
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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
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Blast Injury Physiology
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Blast wave
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Begins as a single pulse of increased pressure that rises to
peak levels in milliseconds
Propagated outward radially from the explosion
Blast winds
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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
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Results directly form the sudden changes in environmental
pressure caused by the blast wave
Tissues vary in susceptibility to primary blast injury
A.
B.
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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
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Ears- most vulnerable organ, primary complaint
is hearing loss
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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
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Lungs- second most vulnerable organ, most severely
affected organ and most likely to present threat to life
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Blast wave produces a diffuse lung contusion causing hemorrhage
and edema
Pleural and lung lacerations
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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
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GI: Rare injuries, requires high pressures
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(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
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1)
2)
Concussions common- present with amnesia and confusion
Cerebral-air embolism- symptoms of stroke, aphasia, focal
paralysis or hemiplegia, sensory deficits
Other injuries:
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Eyes- retinal detachments, IO hemorrhage
Sinuses- ruptured
Categories of Blast Injuries
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Secondary blast injury
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Tertiary blast injury
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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
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Result from inhalation of dust and toxic gases,
exposure to radiation, and thermal burns
Management of Blast Injuries
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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
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Recognize systemic air emboli- MI, PE, CVA
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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
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Chemical Burns
Chemical Burns
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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
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Tissue damage determined by:
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Strength/concentration of agent
Manner of contact
Quantity of agent
Duration of contact
Mechanism of action
Extent of penetration
Chemical Burns
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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
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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
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Liquid Chemicals
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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
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Flush for 20-30 minutes to remove all chemicals
Chemical Burn Management
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Dry Chemical Fear

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Exothermic reaction with water
Not a reason to delay irrigation with water!!!!
Chemical Burn Management
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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
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Lacrimators
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First chemical agents used by police/military
Mucous membrane and respiratory tract irritant
Skin sensitizer
Management
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Treat respiratory distress
Protect yourself first
Continued irrigation and shower
decontamination
Ocular Burns
Ocular Burns
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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
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Decreased myocardial reserve

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Peripheral vascular disease, diabetes

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slow healing
COPD
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fluid resuscitation difficulty
increases complications of airway injury
Poor immunological response - Sepsis
% mortality ~= age + % BSA burned