burns burns. burns john van der steeg md objectives incidence and patterns of burn injury incidence...
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BurnsBurns
BurnsBurnsJohn van der Steeg MDJohn van der Steeg MD
ObjectivesObjectives
Incidence and patterns of burn injuryIncidence and patterns of burn injury Pathophysiology of local and systemic Pathophysiology of local and systemic
responses to burn injuryresponses to burn injury Classify burn Classify burn Physical exam of the burned patientPhysical exam of the burned patient Prehospital management of burned patientPrehospital management of burned patient Signs and symptoms of inhalational injury Signs and symptoms of inhalational injury
which may influence managementwhich may influence management Criteria for transport to a Burn CenterCriteria for transport to a Burn Center
Incidence and Pattern of Burn Incidence and Pattern of Burn TypesTypes
Tissue injury caused by thermal, electrical, Tissue injury caused by thermal, electrical, radiation or chemical agentsradiation or chemical agents
Burns are another form of traumaBurns are another form of trauma Associated with high mortality, lengthy Associated with high mortality, lengthy
rehabilitation.rehabilitation. Greater than 2 million people/yr. seek care Greater than 2 million people/yr. seek care
for burns.for burns. Morbidity and Mortality follow significant Morbidity and Mortality follow significant
patterns regarding gender, age, and patterns regarding gender, age, and socioeconomic status socioeconomic status
SkinSkin
Largest body organ.Largest body organ. Not a passive organ.Not a passive organ.
– Protects underlying tissues from injuryProtects underlying tissues from injury– Temperature regulationTemperature regulation– Acts as water tight sealActs as water tight seal– Sensory organSensory organ
Very young and old have thin skin Very young and old have thin skin thus short contact time = greater thus short contact time = greater damage when compared to mid aged damage when compared to mid aged personspersons
Skin concerns after burnsSkin concerns after burns
InfectionInfection
Problems with thermal regulationProblems with thermal regulation
Inability to maintain normal water Inability to maintain normal water balancebalance
Skin layersSkin layers
Two layers Two layers – EpidermisEpidermis– DermisDermis
EpidermisEpidermis– Outer cells are deadOuter cells are dead– Protective barrier and Protective barrier and
water tight sealwater tight seal– Deeper layers contain Deeper layers contain
pigment to protect pigment to protect against UV radiation against UV radiation and produce stratum and produce stratum corneumcorneum
Skin LayersSkin Layers
DermisDermis– Consists of tough, Consists of tough,
elastic tissue which elastic tissue which contains specialized contains specialized structures such as structures such as hair follicles, sweat hair follicles, sweat glands, blood glands, blood vessels, oil glands, vessels, oil glands, and nerve endingsand nerve endings
Classification of BurnsClassification of Burns
First degree / First degree / superficial burn- superficial burn- painful, red, and painful, red, and dry and blanch dry and blanch with pressure. with pressure.
Classification of BurnsClassification of Burns
22ndnd degree / partial degree / partial thickness burn- thickness burn- characterized by characterized by blisters, injury blisters, injury extends through extends through the dermis to the the dermis to the epidermis, basal epidermis, basal layers of skin are layers of skin are not destroyednot destroyed
Classification of BurnsClassification of Burns
33rdrd degree / full degree / full thickness burns- Entire thickness burns- Entire thickness of dermis thickness of dermis and epidermis is and epidermis is destroyed. Wound destroyed. Wound characterized by characterized by coagulatin necrosis coagulatin necrosis and appears pearly and appears pearly white, charred or white, charred or leathery. Sensation leathery. Sensation and cap refill are and cap refill are absent.absent.
Factors which affect Burn Factors which affect Burn injuryinjury
Water contentWater content Skin thicknessSkin thickness Skin pigmentSkin pigment Presence of absence of insulating Presence of absence of insulating
substancessubstances Peripheral circulationPeripheral circulation
Tissue damage depends on Tissue damage depends on temperature and timetemperature and time
Surface temperature of 44 C (111 F) Surface temperature of 44 C (111 F) begins to produce burns. But is dependent begins to produce burns. But is dependent on exposure time.on exposure time.
Temperature >44C and < 51C (124F) the Temperature >44C and < 51C (124F) the rate of epidermal necrosis doubles with rate of epidermal necrosis doubles with each degree of temperature increase.each degree of temperature increase.
At > 70 C (185F) or greater, exposure time At > 70 C (185F) or greater, exposure time required to cause transepidermal necrosis required to cause transepidermal necrosis is less than 1 second.is less than 1 second.
Normal process of water evaporation is Normal process of water evaporation is accelerated 5 to 15 time to that of normal accelerated 5 to 15 time to that of normal skin.skin.
Pathophysiology of BurnsPathophysiology of Burns(Local response)(Local response)
Based on Jackson’s Based on Jackson’s thermal wound theorythermal wound theory
Zone of hyperemiaZone of hyperemia– Increased blood flow due Increased blood flow due
to normal inflammatory to normal inflammatory responseresponse
Zone of stasisZone of stasis– Potentially viable tissuePotentially viable tissue– Cells are ischemic due to Cells are ischemic due to
clotting and clotting and vasoconstrictionvasoconstriction
Zone of coagulationZone of coagulation– Coagulation necrosis has Coagulation necrosis has
occurredoccurred– Tissue is non viableTissue is non viable
Pathophysiology of BurnsPathophysiology of Burns(Systemic response)(Systemic response)
Hypovolemic shock/”Burn shock”Hypovolemic shock/”Burn shock”– Response proportional to extent of body Response proportional to extent of body
surface injurysurface injury Pulmonary responsePulmonary response Gastrointestinal responseGastrointestinal response Musculoskeletal responseMusculoskeletal response Neuroendocrine responseNeuroendocrine response Metabolic responseMetabolic response Immune responseImmune response Emotional responseEmotional response
Burn injuriesBurn injuries(Primary Survey)(Primary Survey)
Recall that burn patients are first and Recall that burn patients are first and foremost trauma patientsforemost trauma patients
AirwayAirway BreathingBreathing CirculationCirculation DisabilityDisability ExposureExposure
AirwayAirway
Airway controlAirway control– Chin liftChin lift– Jaw thrustJaw thrust– Insert oral Insert oral
pharyngeal airwaypharyngeal airway– Assess need for ET Assess need for ET
intubationintubation Maintain in-line Maintain in-line
cervical cervical immobilization in immobilization in patients at riskpatients at risk
BreathingBreathing
Listen: verify breath soundsListen: verify breath sounds Assess rate and depth of respirationsAssess rate and depth of respirations Administer high flow O2Administer high flow O2 Monitor chest wall excursion in Monitor chest wall excursion in
presence of full thickness torso burnspresence of full thickness torso burns
Inhalational injuryInhalational injury
Present in 10 – 20 % of burn patientsPresent in 10 – 20 % of burn patients Identified in 60 – 70 % of patients Identified in 60 – 70 % of patients
who die in burn centerswho die in burn centers
Airway assessment and Airway assessment and managementmanagement
Humidified 100% O2 by maskHumidified 100% O2 by mask Endotracheal intubation indicated ifEndotracheal intubation indicated if
– Airway obstruction imminent as signaled Airway obstruction imminent as signaled by progressive hoarseness and/or stridorby progressive hoarseness and/or stridor
– LOC is such that airway protective LOC is such that airway protective reflexes are imparedreflexes are impared
Warning signs/cluesWarning signs/clues
Facial burns, singed nasal hairsFacial burns, singed nasal hairs Carbonaceous sputumCarbonaceous sputum Tachypnea, intercostal retractionsTachypnea, intercostal retractions HoarsnessHoarsness Agitation (hypoxia)Agitation (hypoxia) Rales, rhonchi, diminished breath Rales, rhonchi, diminished breath
soundssounds Inability to swallowInability to swallow Naso or oro-pharynx erythemaNaso or oro-pharynx erythema
CirculationCirculation
Monitor BP, pulse rate, skin colorMonitor BP, pulse rate, skin color Establish IV accessEstablish IV access
– If possible, place iv in non-burned skin, If possible, place iv in non-burned skin, but may place it in burned skin if but may place it in burned skin if needed.needed.
– How would you secure IV in burned How would you secure IV in burned tissue?tissue?
Assess circulatory status of Assess circulatory status of circumferentially burned extremitiescircumferentially burned extremities
Disability, Neurologic Disability, Neurologic DeficitsDeficits
Typically alert and oriented. If not, Typically alert and oriented. If not, why not?why not?
Remember AVPU?Remember AVPU?– A-AlertA-Alert– V-Responds to verbal stimuliV-Responds to verbal stimuli– P-Responds to painful stimuliP-Responds to painful stimuli– U-UnresponsiveU-Unresponsive
Disability, Neurologic Disability, Neurologic DeficitsDeficits
Please remember before you Please remember before you intubate, if possible, to get any intubate, if possible, to get any pertinent historypertinent history– AMPLE historyAMPLE history– A – AllergiesA – Allergies– M – MedicationsM – Medications– P – Previous medical/surgical historyP – Previous medical/surgical history– L – Last meal (time)L – Last meal (time)– E – Events/environment surrounding the E – Events/environment surrounding the
injury; ie. Exactly what happenedinjury; ie. Exactly what happened
Exposure/Environmental Exposure/Environmental controlcontrol
First must remove patient to a safe First must remove patient to a safe areaarea
Stop the burning processStop the burning process– Exstinguish fire – cool smoldering areasExstinguish fire – cool smoldering areas– Remove ALL clothing and ALL jewelryRemove ALL clothing and ALL jewelry– Cut around areas where clothing is stuck Cut around areas where clothing is stuck
to the skinto the skin– Cool adherent substances (Tar, Plastic)Cool adherent substances (Tar, Plastic)
Exposure/Environmental Exposure/Environmental controlcontrol
Once patient in safe areaOnce patient in safe area Maintain patient’s temperatureMaintain patient’s temperature
– Warm room or rigWarm room or rig– Keep patient covered; dry sheets, Keep patient covered; dry sheets,
blanketsblankets– Warm IV fluidsWarm IV fluids
Circumstances of Circumstances of InjuryInjury
Circumstances of Injury: Circumstances of Injury: FlameFlame
How did it occur?How did it occur?– Inside or outside?Inside or outside?– Clothing ignition?Clothing ignition?– Time to extinguish flame?Time to extinguish flame?– Extinguished how?Extinguished how?– Gasoline or other fuel involved?Gasoline or other fuel involved?– Explosion? Patient thrown?Explosion? Patient thrown?– Are purported circumstances of injury Are purported circumstances of injury
consistent with burn characteristics?consistent with burn characteristics?
Circumstances of Injury: Circumstances of Injury: FlameFlame
Structure fire?Structure fire? Smoke filled space?Smoke filled space? Others injured or killed in event?Others injured or killed in event? Was there LOC at the scene?Was there LOC at the scene? How did the patient escapeHow did the patient escape
– Did the patient jump? How far was the Did the patient jump? How far was the drop?drop?
– Through glass?Through glass?
Circumstances of Injury: Circumstances of Injury: FlameFlame
Automobile crash?Automobile crash? How badly was the car damaged?How badly was the car damaged? Other injuries?Other injuries? Did they hit anybody? Check around, Did they hit anybody? Check around,
under the vehicle.under the vehicle. Car fire?Car fire?
Circumstances of Injury: Circumstances of Injury: ScaldScald
What is the history of the injury?What is the history of the injury?– What was the liquid?What was the liquid?– What was the volume of liquid involved?What was the volume of liquid involved?– What was the temperature of the liquid? What was the temperature of the liquid?
If tap water, what was the heater temperature If tap water, what was the heater temperature setting?setting?
If heated by other source, was the liquid boilingIf heated by other source, was the liquid boiling
– Was the patient wearing clothing?Was the patient wearing clothing?– How quickly was it removed?How quickly was it removed?– Was the burned area cooled?Was the burned area cooled?– Was other first aid administered?Was other first aid administered?
Circumstances of Injury: Circumstances of Injury: ScaldScald
Is abuse or neglect Is abuse or neglect suspected?suspected?– How quickly was How quickly was
care sought?care sought?– Where did the burn Where did the burn
occur?occur?– Who was with the Who was with the
patient when the patient when the injury occurred?injury occurred?
– Does the story fit Does the story fit the injury?the injury?
Circumstances of Circumstances of Injury:ChemicalInjury:Chemical
Circumstances of Circumstances of Injury:ChemicalInjury:Chemical
What was the agent?What was the agent? Is it still around? Vapor?, Liquid?, Is it still around? Vapor?, Liquid?,
Solid?Solid? How did the exposure occur?How did the exposure occur? What was the duration of contact?What was the duration of contact? What decontamination occurred?What decontamination occurred? Was there an explosion? Was the Was there an explosion? Was the
patient thrown?patient thrown? What is the toxicity of the agent?What is the toxicity of the agent?
Circumstances of Circumstances of Injury:ElectricalInjury:Electrical
What kind of current was involved?What kind of current was involved? What was the duration of contact?What was the duration of contact? Was the patient thrown or did the Was the patient thrown or did the
patient fall?patient fall? What was the estimated voltage?What was the estimated voltage? Was there LOC?Was there LOC? Was CPR administered?Was CPR administered?
Circumstances of Circumstances of Injury:ElectricalInjury:Electrical
The great pretenderThe great pretender– Small surface injuries may be associated Small surface injuries may be associated
with severe internal injurieswith severe internal injuries– Causes about 1000 deaths/yr.Causes about 1000 deaths/yr.
First contactFirst contact
After patient in safe area…After patient in safe area… Complete head to toe examComplete head to toe exam Pre-existing medical conditions? Pre-existing medical conditions?
Tetnus status? Other injuries?Tetnus status? Other injuries?
Determine Burn SeverityDetermine Burn Severity
You must assess % of body surface area You must assess % of body surface area (BSA) involved(BSA) involved
Depth of injury (1Depth of injury (1stst, 2, 2ndnd, or 3, or 3rdrd degree) degree)– Realize that this is difficult to do as burns Realize that this is difficult to do as burns
may “mature” over time AND getting an may “mature” over time AND getting an exact percentage is usually not possibleexact percentage is usually not possible
Age of patientAge of patient Associated / pre-existing disease or Associated / pre-existing disease or
illnessillness Burns to hands, face, genitalia.Burns to hands, face, genitalia.
Extent of BurnExtent of Burn
Initial estimate of 2Initial estimate of 2ndnd and 3and 3rdrd degree burns: degree burns: “rule of nines”“rule of nines”– Adult areas = 9% BSA Adult areas = 9% BSA
or multiplesor multiples– Not accurate for Not accurate for
infants/children due to infants/children due to larger BSA of head and larger BSA of head and smaller BSA of legs.smaller BSA of legs.
To estimate scattered To estimate scattered burns, palm of hands burns, palm of hands and fingers of patient and fingers of patient = 1% BSA= 1% BSA
Burn DepthBurn Depth
Very young and very old patients Very young and very old patients have thinner skinhave thinner skin
Therefore, contact time at similar Therefore, contact time at similar temperatures will be worse for them.temperatures will be worse for them.
Pre-hospital management Pre-hospital management principlesprinciples
Stop the burning processStop the burning process Universal precautionsUniversal precautions Initiate fluid resusucitation per the Initiate fluid resusucitation per the
consensus protocol:consensus protocol:– 2 - 4 ml % BSA burn2 - 4 ml % BSA burn– ½ in 1½ in 1stst 8 hrs 8 hrs– ½ over next 16 hrs½ over next 16 hrs– *this is for adults only, pediatric patients *this is for adults only, pediatric patients
require consensus formula + D5LR require consensus formula + D5LR maintenence fluidsmaintenence fluids
Pre-hospital management Pre-hospital management principlesprinciples
Vital signsVital signs
Assess extremity perfusionAssess extremity perfusion– * remove all rings, watches, other * remove all rings, watches, other
jewelryjewelry– *Elevation of burned areas if possible*Elevation of burned areas if possible
Ventilation statusVentilation status
Pain relief/managementPain relief/management
Initial Burn Wound CareInitial Burn Wound Care
Thermal burnsThermal burns– Cover with clean, DRY clothCover with clean, DRY cloth– NO ice or cold water soaksNO ice or cold water soaks
Initial Burn Wound CareInitial Burn Wound Care
Electrical InjuryElectrical Injury– Be aware of both cutaneous an internal Be aware of both cutaneous an internal
injuryinjury Entrance and exit points versus contact Entrance and exit points versus contact
pointspoints Arcing wounds vs electrical flash woundsArcing wounds vs electrical flash wounds
– Consider electrical current cardiac Consider electrical current cardiac effectseffects
Initial Burn Wound CareInitial Burn Wound Care
Chemical burnsChemical burns– Scene control Scene control – Brush powders from skin and clothesBrush powders from skin and clothes
Watch shoes and socksWatch shoes and socks
– Remove contaminated clothingRemove contaminated clothing– Flush with COPIUS amounts of waterFlush with COPIUS amounts of water– Eye irrigation if involvedEye irrigation if involved– Exposure protection for yourselves and Exposure protection for yourselves and
anyone involved with patient careanyone involved with patient care
Burn center referral criteriaBurn center referral criteria
The ABA identifies the following as The ABA identifies the following as injuries requiring a Burn Center injuries requiring a Burn Center referral:referral:– 22ndnd degree burns > 10% TBSA degree burns > 10% TBSA– Burns to face, hands, feet, genitalia, Burns to face, hands, feet, genitalia,
perineum, major Jointsperineum, major Joints– 33rdrd degree burns degree burns– Electric injury (lightning included)Electric injury (lightning included)– Chemical burnsChemical burns
Burn center referral criteriaBurn center referral criteria
Inhalational injuriesInhalational injuries Burns accompanied by pre – existing Burns accompanied by pre – existing
medical conditionsmedical conditions Burns accompanied by trauma, where Burns accompanied by trauma, where
burn injury poses greatest risk of burn injury poses greatest risk of morbidity or mortalitymorbidity or mortality
Burns to children in hospitals without Burns to children in hospitals without pediatric servicespediatric services
Patients with special social, emotional or Patients with special social, emotional or rehabilitative needsrehabilitative needs
SummarySummary
Be able to assess injuriesBe able to assess injuries Be able to develop priority – based Be able to develop priority – based
plan of careplan of care Base care plan on type, extent, Base care plan on type, extent,
degree of burndegree of burn Consult with a burn center physicianConsult with a burn center physician Decide upon local treatment and Decide upon local treatment and
transport with burn center physiciantransport with burn center physician
Feel that burn…in your Feel that burn…in your coloncolon