Transcript Functions of the Skin - Adirondack Area Network

Emergency Evaluation
and Treatment of Burns
Sarah Seiler,
RN, BSN, NREMT-P
CCRN, CEN
Emergency Medicine Outreach Coordinator
Statistics
• 1.25 million burn injuries per year
• 4,550 fire and burn deaths per year
• 3,750 deaths from house fires
• Fire and burn deaths have declined by
50% since 1971
• 45,000 hospitalizations per year
• 600,000 annual emergency department
visits per year
The Burn Foundation
http://www.burnfoundation.org
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Functions of the Skin
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Protection
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Prevents invasion of environmental toxins and microorganisms
Immunologic
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Sebum has antibacterial properties which helps shed topical
bacteria
Thermoregulation
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Insulates from heat loss and controls loss of heat through
evaporation
Functions of the Skin cont’d
• Fluid and Electrolyte Balance
– Controls sodium excretion
– Sebum retards fluid loss from skin
• Metabolism
– Produces Vitamin D
– Prevents excessive fluid loss
• Neurosensory
– Nerve endings and receptors process environmental stimuli for pain,
touch, heat and cold
• Social and Interactive
– Provides body image and personal identity
Carrougher Burn Care and Therapy
Anatomy and Physiology of the Skin
A and P of the Skin
• Epidermis
• First layer of defense
• Composed of dead, keratinized
cells and surrounded by a lipid
monolayer
• There are no blood vessels. It is
fed by capillaries in the dermis.
• If the epidermis is destroyed but
the appendages of the dermis
remain, a new epidermis is formed
when the epithelial climb up the
hair follicles.
cont’d
A and P of the Skin
• Dermis
• Collagen and fibrous connective
tissue
• Contains capillaries and arterioles
• Has special sensory nerve fibers
and lymph system
– Meissner Corpuscle: light touch, just
beneath epidermis
– Vater Pacini Corpuscles: pressure sensors,
deep in subq
– Ruffini Corpuscles: heat sensors, deep in
subq tissue
– Krause Corpuscles: cold sensors, deep in
subq tissue
cont’d
A and P of the Skin
• Subcutaneous Tissue
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Connective tissue
Fat cells in most areas
Blood vessels
Nerves
Base of hair follicles
Function:
• Insulation
• Storage of nutrients
cont’d
Types of Burns
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Superficial
Superficial partial thickness
Deep partial thickness
Full thickness
Superficial Burn
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Sunburn
Involves only the epidermis
Local pain and erythema
No blister formation
Heals spontaneously without scarring
Systemic response is minimal
Superficial Burn
Partial Thickness Burn
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Can be superficial or deep
Involves epidermis and dermis
Has blister formation
Moist appearance
Tactile and pain sensors intact
Will usually heal on own but will scar
Partial Thickness
Partial Thickness
Full Thickness Burn
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Involves all layer of skin
Has waxy and dry appearance
Elasticity destroyed
Painless
Does not heal without intervention
Full Thickness
Full Thickness
Determining Burn Severity
• Depth of the burn
• Superficial
• Partial thickness
• Full thickness
• Body surface area
Estimating BSA
• Rule of Nines
• Easiest to use, best for field use
• Lund Brower
• More accurate, used in hospital
• Palmar
• Estimates scattered burns
• Patient’s palm is 1% of his/her BSA
Rule of Nines
Rule of Nines for Children
Lund Brower
Initial Treatment
• STOP the burning process
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AIRWAY, AIRWAY, AIRWAY
High flow humidified O2
Remove all clothing – keep warm
Decontaminate chemical burns
Pain control
– Do not give SQ or IM
Signs and Symptoms of
Airway Injury
• Soot around the nose and mouth
• Singed nasal hairs
• Complains of shortness of breath
• Wheezing or rales on auscultation
Signs and Symptoms of
Airway Injury cont’d
• Agitation, tachypnea, anxiety, stupor,
cyanosis
• Disorientation, obtundation, coma
• Hoarse voice, brassy cough
Signs and Symptoms of
Airway Injury cont’d
• Rapid respiratory rate, flaring nostrils,
intercostal retractions
• Stridor
• Sooty sputum
• History of the event
Airway Protection
Edema with Fluid Resuscitation
Edema with Fluid Resuscitation
Inhalation Injury Prognosis
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 risk of nosocomial infection
 length of stay
 cost of hospital care
 mortality by up to 20%
Carbon Monoxide Poisoning
• Hemoglobin has 200-250 times greater affinity for
CO than oxygen
• Most on-scene fatalities are caused by
asphyxiation and/or carbon monoxide poisoning.
• Normally present with normal PaO2
• Usually normal color and no respiratory distress
• Suspect based on history
• Until recently definitive diagnosis could only be
made by measuring carboxyhemoglobin levels in
blood
MASIMO
Signs and Symptoms of
Carbon Monoxide Toxicity
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Signs and Symptoms
Impaired visual acuity
Flushing, headache
Nausea, impaired dexterity
Vomiting, dizziness, syncope
Tachypnea, Tachycardia
Coma, death
Carboxyhemoglobin
Saturation
• 5-10%
• 11-20%
• 21-30%
• 31-40%
• 41-50%
• >50%
Treatment of CO Poisoning
High
Flow
O2 !!!!!!!!!
Fluid Resuscitation
• If <60min from facility, IV not necessary
• Parkland Formula
– 2-3ml/kg/%BSAB
– half given over the first 8hr since burn injury and
half over the second 16
Maintain a urine output of 30-50cc/hr
Adequate Resuscitation
• BP not accurate
–  edema makes BP difficult
• Pulse may be more helpful
– Maintain close to normal range
• Urine output is most accurate in adult
– Maintain between 30-50cc/h
Resuscitation Made Easy
• If burn (2° or 3° ) greater than 15% of total
body surface (or if there are other injuries)
Infuse lactated Ringers (Estimate of
Requirements):
– 15-25% TBS = 500 ml per hour
– 25-50% TBS = 750 ml per hour
– > 50% TBS = 1 Liter per hour
The Burn Injury Results In
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Decreased cardiac output
Increased heart rate
Decreased tissue perfusion
Stasis of blood
Tissue ischemia
Anaerobic metabolism
Metabolic acidosis
Fluid and Protein Loss
Special Considerations
for Resuscitation
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Elderly
Pediatric
Electrical burns
Pre-existing cardiopulmonary conditions
Circumferencial Burns of the Chest
Circumferencial Burns of the Chest
Escharotomy
Pediatric Statistics
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Second leading cause of death
250,000 children each year
15,000 are hospitalized
1,100 deaths from fire and burn injuries
The Burn Foundation
http://www.burnfoundation.org
Pediatric Statistics
• 100,000 are burned from scalds from
spilled food and beverages
• 18,700 are burned by curling and clothing
irons
• 3,200 burned by fireworks
• 1,500 burned by gasoline and matches
• 1,500 burned by cigarettes
The Burn Foundation
http://www.burnfoundation.org
Pediatrics
• Reliable indicators of adequate
resuscitation
– Mental clarity
– Pulse pressures
– Arterial blood gases
– Distal extremity color
– Capillary refill
– Body temperature
Pediatric Abuse
Electrical Burns
Electrical Burn to the Hand
This is the Same Hand!!!!
Treatment for Electrical Burns
• Scene Safety
– Remove from source after disconnecting
• ABCs
• 12 lead EKG
– Nonspecific ST changes and A fib most common
• IV
– Usually require more fluid
• Labs
– CK-MB to check for muscle damage
Long Term Treatment
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Early exploration of wound (within 24h)
Debridement
Fasciotomy
Amputation
Increased Risk of Cardiac Damage
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Loss of consciousness
Documented cardiac arrhythmia
Abnormal EKG
Chest pain and palpitations
Complications
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Renal failure
Pulmonary Edema
Infection
Acidosis
Cardiac dyrhythmias
Cardiac arrest
Myocardial injury
Amputation
Urine Myoglobin
• What is it?
– Large protein released from
damaged renal tubules.
– Can occlude renal tubules and
cause renal failure.
– Usually in very large, deep or
electrical burns.
Treatment for Myoglobinuria
• Increase IVF to maintain UO at 75-100cc/h
• Administer NaHCO3 to buffer the kidney
Chemical Burns
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Can be liquid, solid, or gas
Usually deeper than it looks
Appearance is brown to gray
If have severe persistent pain, it is still
burning.
• Some can lead to systemic poisoning (i.e.
phenol and gasoline)
Treatment for Chemical Burns
• ABCs
• Remove clothing and constrictive objects
(jewelry)
• Obtain a good history
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Place, nature, and duration of exposure
What are the chemicals
Specific toxic properties
Relevant patient history
Current symptoms
Chemical Wound Management
• Brush off chemicals first
• Continuously irrigate for 20-30min
minimum
• Do NOT attempt to neutralize acids or
alkalis.
• Notify ED PTA if unable to decontaminate
Lime Burn
Sulfuric Acid
Tar
Asphalt
Methamphetamine Labs
• In 2002, more than 7,500 labs seized in 44
states.
• Can be located anywhere from apartment to
trailer to house to car to motel
•Signs of Lab
•Unusual odors
•Excessive amounts of trash, especially
chemical containers
•Curtains drawn or covered with
aluminum foil
•Extensive security measures
•Frequent visitors at unusual times
Methamphetamine Lab Risks
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May ignite or explode easily
Chemical burns
SOB, cough, chest pain
Possible Ingredients
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Pseudoephedrine
Acetone/ethyl alcohol
Freon
Anhydrous ammonia
Red phosphorus
Lithium metal
Hydriodic acid
Iodine crystals
phenylprpanolamine
Methamphetamine Labs
• Common Equipment
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Aluminum foil
Blenders
Cheesecloth
Clamps
Coffee filters
Jugs and bottles
Lab beakers
Measuring cups
Propane cylinders
Rubber gloves
Strainers
thermometer
• Common Products
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Acetone
Alcohol (isopropyl or rubbing)
Pseudoephedrine
Ether (engine starter)
Hydrochloric acid (pool
supply)
Iodine
Kitty litter
Salt
Lye
Sulfuric acid (drain cleaner)
Toluene (brake cleaner)
Trichloroethane (gun cleaner)
Methamphetamine Behavior
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Psychiatric symptoms
 aggressiveness
Arrhythmias
MI
Cerebral hemorrhage
Anorexia
With withdrawal
– ↓ psycomotor performance
– Accumulated sleep debt
Methamphetamine Burns
• More likely to have inhalation injury
• Greater extent of full thickness burns
• Increased risk of nosocomial pneumonia
and respiratory failure
• Increased risk of sepsis
• Longer hospital and ICU stays
• Higher mortality
Cyanide
• In 1998, 350 documented cyanide deaths
• Hydrogen cyanide in wool, silk,
polyurethane (furniture cushion), urea
formaldehyde, melanine (dishwasher),
acetonitrile (artificial fingernail remover)
• Common in metal trades, mining,
electroplating, jewelry manufacturing, xray
films
• Cassava (potato), apricot pits
Cyanide Poisoning
• More difficult to diagnose than CO poisoning
• Common with smoke inhalation from residential
and industrial fires.
• Used in suicide
• Suspect in patients with an unexplained
metabolic acidosis and elevated lactic acid
levels because shifts cellular metabolism from
aerobic to anaerobic
• Individuals who survive have increased risk for
CNS dysfunction
Cyanide Poisoning
Signs and Symptoms
• May be delayed depending on type, route, and
dose
• Headache, vertigo, dizziness, giddiness,
inebriation, confusion
• Seizures
• Coma
• Shortness of breath, tachypnea, apnea
• Abd pain, nausea, vomiting
• General weakness, malaise
Cyanide Poisoning
Signs and Symptoms
• Initial bradycardia and hypertension may
quickly change to hypotension
• Pulse oximetry inaccurate
• Cherry red skin color (rare and late)
• Smell of bitter almonds on breath (60% of
population)
• Soot in mouth and nose if smoke
inhalation
Cyanide Poisoning Treatment
• Scene safety/Decontaminate
• Airway protection
• EKG
– May show AV blocks, SVT, Ischemia, Asystole
• Sodium Bicarb if unconscious or
hemodynamically unstable and acidotic
• Cyanide antidote kit =amyl nitrite, sodium
nitrite, and sodium thiosulfate
– Don’t use sodium nitrite in smoke inhalation because
↓ carrying capacity if blood
Cyanide Poisoning Treatment
• Arterial and venous blood gas
– Metabolic acidosis and ↓ oxygen
• Lactic acid levels
– >10mmol suggest cyanide
• Carboxyhemoglobin
• Plasma cyanide concentration
• Methomoglobin
– For monitoring nitrite therapy
Special Concerns in Pregnancy
with Cyanide
• Fetal demise is possible
• Aggressive support and antidotal
treatment of mother is imperative
• Obstetric evaluation after stabilization
• Therapeutic abortion may be necessary in
fetal demise
Burn Center Referral Criteria
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Partial thickness burns > 10% TBSA
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Burns that involve the face, hands, feet,
genitalia, perineum, or major joints
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Third degree burns in any age group
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Electrical burns, including lightening injury
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Inhalation injury
Burn Center Referral Criteria cont’d
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Burn injury in patients with preexisting medical disorders
that could complicate management, prolong recovery, or
affect mortality.
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Any burn injury with concomitant trauma in which the
burn injury poses the greatest risk of morbidity or
mortality.
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Burned children of any degree should be transferred to a
facility equipped to care for them.
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Burn injury in patients who will require special social,
emotional, or long-term rehabilitation
American Burn Association
Transportation
References
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American Burn Association www.ameriburn.org
Arnoldo, B. et al. Practice guidelines for the management of electrical burns. Journal of
Burn Care and Research. 2006;27:439-447.
www.burnsurgery.org
Carrougher, G. Burn Care and Therapy. Mosby;1998.
Sai, N. et al. The comparison of early fluid therapy in extensive flame burns between
inhalation and noninhalation. Burns. 1998;24:671-5.
Herndon, D. Total Burn Care 2nd Edition. Elsevier Science;2001.
Leybell, I. et al. Cyanide Toxicity. Emedicine. 2006.
http://www.emedicine.com/emerg/topic/topic118.htm
National Drug Intelligence Center, U.S. Department of Justice. Methamphetamine
Laboratory Identification and Hazards. http://www.usdoj.gov/ndic
Spann, M, et al. Characteristics of burn patients injured in methamphetamine laboratory
explosions. Journal of Burn Care and Research. 2006;27:496-501.
Tomaszewski, M.D. C. Carbon monoxide poisoning: early awareness can save lives.
Postgraduate Medicine. 1999; 105