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Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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Page 1: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Emergency Evaluation and Treatment of

Burns

Sarah Seiler, RN, BSN, NREMT-P

CCRN, CEN

Emergency Medicine Outreach Coordinator

Page 2: 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 yearThe Burn Foundation

http://www.burnfoundation.org

Page 3: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Burn survival graph

Page 4: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Functions of the Skin• Protection

– Prevents invasion of environmental toxins and microorganisms

• Immunologic – Sebum has antibacterial properties which helps shed topical

bacteria

• Thermoregulation – Insulates from heat loss and controls loss of heat through

evaporation

Page 5: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 6: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Anatomy and Physiology of the Skin

Page 7: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

A and P of the Skin cont’d

• 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.

Page 8: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

A and P of the Skin cont’d

• 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

Page 9: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

A and P of the Skin cont’d

• Subcutaneous Tissue• Connective tissue• Fat cells in most areas• Blood vessels• Nerves• Base of hair follicles• Function:

• Insulation• Storage of nutrients

Page 10: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Types of Burns

• Superficial

• Superficial partial thickness

• Deep partial thickness

• Full thickness

Page 11: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Superficial Burn

• Sunburn

• Involves only the epidermis

• Local pain and erythema

• No blister formation

• Heals spontaneously without scarring

• Systemic response is minimal

Page 12: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Superficial Burn

Page 13: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Partial Thickness Burn

• 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

Page 14: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Partial Thickness

Page 15: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Partial Thickness

Page 16: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Full Thickness Burn

• Involves all layer of skin

• Has waxy and dry appearance

• Elasticity destroyed

• Painless

• Does not heal without intervention

Page 17: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Full Thickness

Page 18: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Full Thickness

Page 19: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Determining Burn Severity

• Depth of the burn• Superficial• Partial thickness • Full thickness

• Body surface area

Page 20: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 21: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Rule of Nines

Page 22: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Rule of Nines for Children

Page 23: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Lund Brower

Page 24: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Initial Treatment

• STOP the burning process

• AIRWAY, AIRWAY, AIRWAY• High flow humidified O2• Remove all clothing – keep warm• Decontaminate chemical burns• Pain control

– Do not give SQ or IM

Page 25: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator
Page 26: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator
Page 27: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 28: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Signs and Symptoms of Airway Injury cont’d

• Agitation, tachypnea, anxiety, stupor, cyanosis

• Disorientation, obtundation, coma

• Hoarse voice, brassy cough

Page 29: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Signs and Symptoms of Airway Injury cont’d

• Rapid respiratory rate, flaring nostrils, intercostal retractions

• Stridor

• Sooty sputum

• History of the event

Page 30: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Airway Protection

Page 31: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Edema with Fluid Resuscitation

Page 32: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Edema with Fluid Resuscitation

Page 33: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Inhalation Injury Prognosis

• risk of nosocomial infection

• length of stay

• cost of hospital care

• mortality by up to 20%

Page 34: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 35: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

MASIMO

Page 36: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Signs and Symptoms of Carbon Monoxide Toxicity

CarboxyhemoglobinSaturation• 5-10%• 11-20%• 21-30%• 31-40%• 41-50%• >50%

Signs and Symptoms• Impaired visual acuity• Flushing, headache• Nausea, impaired dexterity• Vomiting, dizziness, syncope• Tachypnea, Tachycardia• Coma, death

Page 37: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Treatment of CO Poisoning

High

Flow

O2 !!!!!!!!!

Page 38: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 39: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 40: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator
Page 41: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 42: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator
Page 43: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

The Burn Injury Results In

• Decreased cardiac output

• Increased heart rate

• Decreased tissue perfusion

• Stasis of blood

• Tissue ischemia

• Anaerobic metabolism

• Metabolic acidosis

Page 44: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Fluid and Protein Loss

Page 45: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Special Considerationsfor Resuscitation

• Elderly

• Pediatric

• Electrical burns

• Pre-existing cardiopulmonary conditions

Page 46: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Circumferencial Burns of the Chest

Page 47: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Circumferencial Burns of the Chest

Page 48: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Escharotomy

Page 49: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Pediatric Statistics

• 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

Page 50: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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 Foundationhttp://www.burnfoundation.org

Page 51: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Pediatrics• Reliable indicators of adequate

resuscitation– Mental clarity– Pulse pressures– Arterial blood gases– Distal extremity color– Capillary refill– Body temperature

Page 52: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Pediatric Abuse

Page 53: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Electrical Burns

Page 54: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator
Page 55: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Electrical Burn to the Hand

Page 56: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

This is the Same Hand!!!!

Page 57: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 58: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Long Term Treatment

• Early exploration of wound (within 24h)

• Debridement

• Fasciotomy

• Amputation

Page 59: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Increased Risk of Cardiac Damage

• Loss of consciousness

• Documented cardiac arrhythmia

• Abnormal EKG

• Chest pain and palpitations

Page 60: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Complications• Renal failure• Pulmonary Edema• Infection• Acidosis • Cardiac dyrhythmias• Cardiac arrest• Myocardial injury• Amputation

Page 61: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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.

Page 62: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Treatment for Myoglobinuria

• Increase IVF to maintain UO at 75-100cc/h

• Administer NaHCO3 to buffer the kidney

Page 63: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Chemical Burns• 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)

Page 64: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Treatment for Chemical Burns

• ABCs

• Remove clothing and constrictive objects (jewelry)

• Obtain a good history– Place, nature, and duration of exposure – What are the chemicals– Specific toxic properties– Relevant patient history– Current symptoms

Page 65: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 66: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Sulfuric Acid

Lime Burn

Page 67: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Asphalt

Tar

Page 68: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 69: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Methamphetamine Lab Risks

• May ignite or explode easily• Chemical burns• SOB, cough, chest pain• Possible Ingredients

– Pseudoephedrine– Acetone/ethyl alcohol– Freon– Anhydrous ammonia– Red phosphorus– Lithium metal– Hydriodic acid– Iodine crystals– phenylprpanolamine

Page 70: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Methamphetamine Labs• Common Equipment

– Aluminum foil– Blenders– Cheesecloth– Clamps– Coffee filters– Jugs and bottles– Lab beakers– Measuring cups– Propane cylinders– Rubber gloves– Strainers– thermometer

• Common Products– 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)

Page 71: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Methamphetamine Behavior• Psychiatric symptoms • aggressiveness• Arrhythmias• MI• Cerebral hemorrhage• Anorexia• With withdrawal

– ↓ psycomotor performance– Accumulated sleep debt

Page 72: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 73: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 74: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 75: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 76: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 77: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 78: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 79: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

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

Page 80: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Burn Center Referral Criteria• Partial thickness burns > 10% TBSA

• Burns that involve the face, hands, feet, genitalia, perineum, or major joints

• Third degree burns in any age group

• Electrical burns, including lightening injury

• Inhalation injury

Page 81: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Burn Center Referral Criteria cont’d

• Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.

• Any burn injury with concomitant trauma in which the burn injury poses the greatest risk of morbidity or mortality.

• Burned children of any degree should be transferred to a facility equipped to care for them.

• Burn injury in patients who will require special social, emotional, or long-term rehabilitation

American Burn Association

Page 82: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

Transportation

Page 83: Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

• 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

References