Transcript Document
Chapter 21
Burns
Topics
Introduction to Burn Injuries
Pathophysiology of Burns
Assessment of Thermal Burns
Management of Thermal Burns
Assessment and Management of
Electrical, Chemical, and Radiation
Burns
Introduction to
Burn Injuries
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
Pathophysiology of Burns
Types of Burns
Thermal (heat)
Electrical
Chemical
Radiation
Thermal 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
Functions of the Skin
Skin is the largest organ.
Functions:
Mechanical barrier
Protective barrier
Sensory organ
Temperature regulation
Epidermis
Dermis
Subcutaneous
Tissue
Thermal 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
Thermal Wounds
Zone of Hyperemia
Zone of Stasis
Zone of Coagulation
Body’s Response to Burns
Emergent Phase (Stage 1)
Happens immediately
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 Burns
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 Burns
Courtesy of David Effron, M.D.
Courtesy of Bonnie Meneely, EMTP
Electrical 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 Burns
Ohm’s Law
V: Voltage
R: Resistance
I: Current
V IR
V
I
R
Based on electron flow thru Tungsten
Emit more light the more current passed
through
Electrical Burns
Joule’s Law
PI R
2
P: Power
I: Current
R: Resistance
Skin is resistant to electrical flow
Electrical Burns
Greatest heat occurs at the points of
higher 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 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 Burns
ACID BURN
Chemical Burns
Chemical destroys tissue
Acids
Form a thick, insoluble mass where they
contact tissue.
Coagulation necrosis
• Limits burn damage
Alkalis
No protective coagulum
Destroys cell membrane through
liquefaction necrosis
• Deeper tissue penetration and deeper burns
Radiation Injury
Radiation
Transmission of energy
Nuclear Energy
Ultraviolet light
Visible Light
Heat
Sound
X-Rays
Radioactive Substance
Emits ionizing radiation
Radionuclide or Radioisotope
Radiation Injury
Basic 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 Injury
Basic Physics
Isotopes
Atoms with unstable nuclear composition
Ionizing Radiation
Half-life
Time required for half the nuclei to lose
activity through decay
Radiation Injury
Radioactive Substances
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 Injury
Radioactive Substances
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
Factors Affecting
Exposure to Radiation
Duration of exposure
Distance from the source
Shielding from the source
Radiation Effects 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
minutes-weeks
Long-Term Effects
Effects years or
decades later
Radiation Injury: Safety
Clean Accident
TIME
DISTANCE
Exposed to radiation
Not contaminated by
products
Properly
decontaminated
Little danger to
personnel
Dirty Accident
SHEILDING
Assoc with Fire at
scene of radiation.
Accident
Trained
Decontamination
Personnel
Radiation Injury
Management
Refer to BLS standards
Park upwind and uphill
Notify Police, Fire & Haz-Mat
Identify radioactive material
Decontaminate patients before care
Routine medical care (ABC’s, etc)
Inhalation Injury
Toxic Inhalation
Synthetic resin and plastic combustion
Produces Cyanide & Hydrogen Sulfide
Systemic poisoning
More frequent than thermal inhalation burn
Affects can be immediate or delayed
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 Injury
Airway Thermal Burn
Supraglottic structures absorb heat and prevent lower
airway burns
Moist mucosa lining insulates and absorbs heat
Superheated steam can injury lower airway
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 Burn
Superficial Burn
Partial Thickness Burn
Full Thickness Burn
Burn Depth
Superficial
Burn:
1st Degree
Burn
Signs &
Symptoms
Reddened skin
Pain at burn site
Involves only
epidermis
Burn Depth
PartialThickness
Burn: 2nd
Degree Burn
Signs &
Symptoms
Intense pain
White to red skin
Blisters
Involves
epidermis &
dermis
Partial-Thickness Burns
1st & 2nd Degree
First Degree Burn
Second Degree Burn
Burn 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
Full-Thickness Burns
3rd Degree
Partialthickness
Full-thickness
Eschar
Body 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 Nines
4.5
4.5
18
18
4.5
4.5
4.5
9
4.5
1
9 9
9
4.5
18
9 9
4.5
18
1
7
7
7
Rule of Palms
A burn equivalent to the size of
the patient’s hand is equal to 1%
body surface area (BSA)
Systemic Complications
Hypothermia
Disruption of skin and its ability to thermoregulate
Hypovolemia
Shift in proteins, fluids, and electrolytes to the
burned tissue
Loss of osmotic pressure
General electrolyte imbalance
Eschar
Hard, leathery product of a deep full thickness burn
Dead and denatured skin constricts over the wound
Increased pressure from edema and restricts
blood flow
Systemic Complications
Infection
Greatest risk of burn is infection
Organ Failure
Kidneys
Liver
Heart
Special Factors
Age & Health
Physical Abuse
Elderly, Infirm or Young
Assessment of
Thermal Burns
Scene Size-up
Fire Department
SCBA and protective clothing
Stop any continued burning on the patient
MOI
Primary Assessment
ABC’s MUST be intact
Rapid transport for any airway burns
Rapid evacuation of patient if scene is
unstable
Assessment of
Thermal Burns
Head/Neck, Chest, Abdomen, Pelvis,
Extremities
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, current illnesses
Assessment of Thermal Burns
General Signs & Symptoms
Pain
Changes in skin
condition at affected
site
Adventitious sounds
Blisters
Sloughing of skin
Hoarseness
Dysphagia
Dysphasia
Burnt hair
Edema
Paresthesia
Hemorrhage
Other soft tissue
injury
Musculoskeletal
injury
Dyspnea
Chest pain
Assessment of Thermal Burns
Burn Severity
Minor
Superficial
Partial Thickness
Full Thickness
<50% BSA
<15% BSA
<2% BSA
Moderate
Superficial
Partial Thickness
Full Thickness
>50% BSA
>15% BSA
>2% BSA
Critical
Partial Thickness
>30% BSA
Full Thickness
Inhalation Injury
>10% BSA
Any partial or full thickness burn involving hands, feet, joints,
face, or genitalia
Assessment of
Thermal Burns
Burns to the face, hands, feet,
joints, genitalia, and
circumferential burns are of special
concern.
Ongoing Assessment
Non-critical: Reassess Q 15 min
Critical: Reassess Q 5 min
Burn Center Care
Management of
Thermal Burns
Local & Minor Burns
Local cooling
Partial thickness: <15% of BSA
Full thickness: <2% BSA
Remove clothing
Comfort and Support
Consider analgesics
Management of Thermal Burns
Moderate to Severe Burns
Sterile dressings
Wet vs Dry dressings
Partial thickness: >15% BSA
Full thickness: >5% BSA
Burn surfaces contacting each other
Maintain warmth
Prevent hypothermia
Consider aggressive fluid therapy
Moderate to severe burns
Burns over IV sites
Place IV in partial thickness burn site.
Management of Thermal Burns
Moderate to Severe Burns
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
Management of Thermal Burns
Moderate to Severe Burns
Caution for fluid overload
Frequent auscultation of breath sounds
Consider analgesic for pain
Morphine
Nubain
Prevent infection
Clean environment
Sterile dressings and sheets
Inhalation Injuries
Carbon monoxide
poisoning
Toxic gas inhalation
Smoke inhalation
Heat inhalation
Steam inhalation
Asphyxiation
Signs of Inhalation Injury
Courtesy Roy Alson, M.D.
Burns of face or
mouth
Singed facial hair
Sooty sputum
Hoarse voice or
stridor
Cough or dyspnea
History of
exposure in
enclosed space
Management of Thermal Burns
Inhalation Injury
Provide high-flow O2 by NRB
Rapid transport if swelling
Consider hyperbaric oxygen
therapy
Cyanide Exposure
Antidote is a 2 stage process
Forms methemoglobin binds to
cyanide
Non-toxic substance secreted in
urine
Assessment & Management of
Electrical Burns
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 of
Electrical Burns
Assess patient
ABC’s + Immobilize c-spine
Entrance & Exit wounds
Remove clothing, jewelry, and leather items
Treat any visible injuries
Thermal burns
ECG monitoring
Bradycardia, Tachycardia, VF or Asystole
• AED Protocols ACLS Protocols
Treat cardiac & respiratory arrest
Aggressive airway, ventilation, and circulatory
management.
Assessment & Management of
Chemical Burns
Scene size-up
Hazardous materials team
Establish hot, warm and cold zones
Prevent personnel exposure from chemical
General burn treatment protocols
Specific Chemicals
Phenol
Dry Lime
Sodium
Riot Control Agents
Treatment of Chemical
Exposure
BSI precautions.
Remove and bag all
contaminated clothing.
Brush off dry chemical.
Flush with copious
amounts of water.
Wipe or scrape any
retained chemical and
irrigate again.
Chemical Burns
Only use water to neutralize
chemical.
Flush affected area for 15-20 minutes
Never use other chemicals to
neutralize.
Chemical A + chemical B = chemical AB +
heat
Collect runoff water if hazardous.
Assessment & Management of Specific
Chemical Burns
Phenol
Industrial cleaner
Alcohol dissolves Phenol
Irrigate with copious amounts of water
Dry Lime
Strong corrosive that reacts with water
Remove clothes and brush off dry substance
Irrigate with copious amounts of cool water
Prevents reaction with patient tissues
Assessment & Management of Specific
Chemical Burns
Sodium
Unstable metal
Reacts vigorously with water
Releases
• Extreme heat
• Hydrogen gas
• Ignition
Decontaminate: Brush off dry chemical
Smother with sand of dirt
Cover the wound with oil substance
Assessment & Management of Specific
Chemical Burns
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
Assessment & Management of
Radiation Burns
Notify Hazardous Materials Team
Personnel positioned Upwind and Uphill
Use older rescuers for recovery
Decontaminate ALL rescuers,
equipment and patients
BLS standards
Remove contaminated clothing
Wrap in double blankets
Isolate, label and dispose of contaminated
equipment and supplies
Radiation Injury Whole Body Exposure
RAD vs. Body Effects
(RAD)
5-25
Effect
50-75
Asymptomatic
Asymptomatic, WBC changes
75-125
Anorexia, N/V and Fatigue in 2 days
125-200
N/V, Diarrhea, Anxiety, Tachycardia
200-600
N/V, Diarrhea, Weakness & Fatigue in Hours
50% Fatal within 6 weeks without Med Care
6001,000
N/V, Diarrhea in hours
100% Fatal within two weeks with Med. Care
1,000+
Burning sensation in minutes, N/V in 10 min
Confusion ataxia, Watery Diarrhea in 2 hrs
100% Fatal in short time
Radiation Injury
Local Exposure (RAD) vs Local Effect
(RAD)
50
500
2,500
Effect
Asymptomatic
Asymptomatic (usually), Altered function of
exposed area
Atrophy, vascular lesion, altered pigment
5,000
Chronic ulcer, risk of cancer
50,000
Permanent destruction of exposed tissue
Ongoing assessment
Re-evaluate initial assessment
Re-evaluate all interventions
Summary
Pathophysiology of Burns
Assessment of Thermal Burns
Management of Thermal Burns
Assessment & Management of
Electrical, Chemical, and Radiation
Burns