PCP - GORD PATTERSON, ALS-A//V , ACP

Paramedic Burn Care

Primary Care Paramedics: a critical link allowing serious Burns to

achieve maximally favourable outcomes

Burns must grab your attention You will be faced with this sometime in

your career

Visual appearance of injury can create anxiety and scene management challenges

Goal Today is to prepare you to manage burns

To reinforce an understanding of the anatomy and the pathophysiology of burn dynamics.

To enable the student to assess burn

characteristics to thereby provide appropriate care to the burn victim.

Focus on thermal burns Burns described Skin anatomy and function Respiratory considerations Fluid shifting Burn Depth and Zones Burn Severity Size estimations PCP management considerations Dressing considerations & characteristics

Format – 2.5 hours

Introduction P/P Presentation Break out group Burn Classification

Group discussion P/P Presentation Break out group Burn size estimation

Group discussion P/P Presentation Summary

Fast Facts

Burns are commonCreate complex medical challengesCan be disfiguring and disabling2nd leading cause of accidental death in

Canada ~ 412 yearly. ~ 40 are children (Fire Prevention Canada)

Serious medical issue

~ 73% of deaths are from fires in the home

Scalding by liquids is the leading cause of pediatric burn injuries

2,000,000 treatments yearly in Canada and USA

Burns described

A burn is an injury to tissues caused by heat, flame, chemicals, radiation, friction. Burns are classified as ThermalChemicalElectricalRadiation

Burns characteristics defined by :

Mechanism of injury Depth of tissue damage Severity of injury to the patient Total body surface involved

Scalds Contact Burns Fire Chemical Electrical Radiation

Injury mechanisms are further grouped

Review of skin A & P

Skin is the largest organ of the body Surface area is approx 1.8 m2 in adults

and .025 m2 in children It is the most exposed body organ and

prone to burns It makes up 12 – 15% of body mass

Skin Function Summary

Provides protection against infection Retains body fluids Sensory organ and information gatherer Assists in maintaining body temperature Protects internal organs Vitamin D production Expressive communication

Skin Layers Epidermis – thinnest layer

Tough protective barrierProtects internal organsSensory aid

DermisContains blood vessels, nerve endingsPrevents water loss (evaporation)Prevents heat loss

HypodermisSubcutaneous tissue primarily fat, connective

tissue, and vascular structure

Skin – Rich in vascular structures

Burns damage vascular structure creating capillary permeability & fluid shifting

Imagine this over 30% TBSA

Picture source emedicine.com

Fluid shifting occurs in two stages

Hypovolemic stage ( onset to ~ 36-48 hours)

Diuretic stage ( ~ 48 - 72 hours after injury)

Rapid fluid shifts - from the vascular compartments into the interstitial spaces

Capillary permeability increases with vasodilation, cell damage, and histamine release

Fluid loss deep in wounds -Initially Sodium and H2O -Protein loss - hypoproteninemiaHemoconcentration - Hct increasesLow blood volume, oliguriaHyponatremia - loss of sodium with fluidHyperkalemia - damaged cells release K, oliguriaMetabolic acidosis

Hypovolemic Stage

Diuretic StageCapillary membrane integrity returnsEdema fluid shifts back into vessels - blood

volume increasesIncrease in renal blood flow - result in

diuresis (unless renal damage)Hemodilution - low Hct, decreased

potassium as it moves back into the cell or is excreted in urine with the diuresis

Fluid overload can occur due to increased intravascular volume

Metabolic acidosis - HCO3 loss in urine, increase in fat metabolism

Respiratory System

The airway epithelium are susceptible to injury from inhaled hot gases and can be life threatening

Mucous membranes of the nose, mouth, and oropharynx

Epiglottis, glottis and vocal cords Epithelium of the lower respiratory track

Air Flow Obstruction – hypoxia & HypercarbiaBurn gas by-product such as Carbon Monoxide can

displace oxygen creating hypoxia

Airway burns account for the majority of immediate and delayed deaths from burns (death up to 24 hours from injury)

Continually monitor pulmonary status

Signs of a Respiratory Burn Red Flags

History of a Closed area heat insultProductive coughDyspneaFacial burnsSinged nasal hairSooty sputumHorse voice

Primary care of any burns begins with:

Classification of burn depth Estimation of burn size

Classification of burn depth is determined by structures injured

Increasing severity

Traditional Classification 1st degree

Epiderminal layer, red, painful 2nd degree

Epiderminal layer and some dermis, blisters, painful

3rd degreeFull thickness epidermis, all dermis including

hypodermis 4th degree

Full thickness including hypodermis and deep facia

New Classification

Superficial Superficial Partial Thickness Deep Partial Thickness Full Thickness Fourth Degree

Superficial Burns

Involve only the epidermal layer of skin. RedDryPainfulBlanches

Heals spontaneously

Superficial

Superficial Partial Thickness

Involve entire epidermis and superficial portions of the dermisPainful , red and weeping usually from

blistersBlanches with pressure

Generally heals spontaneously

Superficial Partial Thickness

Deep Partial Thickness

Involve entire epidermis Extends into deeper dermis damaging

glandular tissue and hair follicles BlistersWet or waxy dryVariable colour from patchy white to red

May heal spontaneously

Deep Partial Thickness

Full Thickness Burns

Includes destruction of epidermis, the entire dermis

Damage to the hypodermisWaxy white to leathery grey to charred and

black Less painful May require skin grafting

Full Thickness Burn

Fourth Degree Burns

Includes destruction of epidermis, the entire dermis and the hypodermis

Destruction of the hypodermis Deep facia, variable colour, leathery, bone

exposure Less painful Requires skin grafting

Fourth degree burn

Break Out Group Pictures Four Groups 15 minutes Choose speaker to discuss burn

Object: Assess Burn Depth

Burn classificationDistinguishing featuresSkin structures involved

Notions

Burns are generally have a combination of varying degrees and zones of burn classification in the same injury

All burns are painful All victims are frightened Burns have a “Wow Factor” and an

unforgettable aroma

A single burn can be made up of combination of classifications

Cell damages occurs in varying degrees creating Burn Zones

Identify tissue viability

Critical burn body areas are: Respiratory tract Face, eyes Hands & feet joint areas Perineum Circumferential burns

Circumferential burns constrict circulation

How does this occur

Encircling damaged skin (eschar) looses elasticity and constricts damaged tissues by compartmentalizing fluid shifting in underlying tissues increasing interstitial pressures that compress vascular structures and nervesTissue hypoxia Further tissue & cell damage

Fixes: Escharotomy or Fasiotomy

Is this patient sick?

Severity of injury is dependent on Size of burn or Total Body Surface Area

injured (TBSA) Classification or depth of injury Critical area involvement Age Prior health status Location of burn Associated injuries

Accurate burn size estimation is essential to determine severity Rule of Nines

Palmer MethodThe area of the patient’s hand size including

the fingers is approximately 1% TBSA

Adult:Head 9%Arms 9%(each)Torso (front/back)18%Legs 18%Perineum 1%

Child:Head18%Arms 9% (each)Torso (front/back) 18% Legs14% (each)Perineum1%

Rule of Nines

Severity is further described as:

Minor Burn

<10 percent TBSA burn in adult <5 percent TBSA burn in young or old <2 percent full thickness burn

Minor

Moderate Burn

10 to 20 percent TBSA burn in adult 5 to 10 percent TBSA burn in young or old 2 to 5 percent full-thickness burn High-voltage injury Suspected inhalation injury Circumferential burn Concomitant medical problem predisposing

the patient to infection (e.g., diabetes, sickle cell disease)

Moderate

Major Burn

>20 percent TBSA burn in adult >10 percent TBSA burn in young or old>5 percent full-thickness burn High-voltage burnKnown inhalation injuryAny significant burn to face, eyes, ears, genitalia

or jointsSignificant associated injuries (e.g., fracture,

other major trauma)

Major

Break Out Group Pictures Four Groups 15 minutes Choose speaker to discuss burn

Object:

Assess Burn Size TBSASeverityStructures involved

Burn Mortality

Management is focused to prevent mortality and morbidly

Death from burns Initial 24 hours:

respiratory burnhypovolemic shock

After 24 hours:infection kidney failure

Primary Burn Management Scene Safe ABC’s Expose and examine

Remove constricting jewellery/watches Initiate cooling (Thermal) Flush chemicals off (Chemical) High flow oxygen Calculate TBSA Evaluate injury depth Evaluate injury severity

Burn Priorities Timely transport! Prepare for urgent A/W interventions

BV Mask passive assistanceALS backup

Infection control (Damaged tissue & vascular bed ideal conditions for bacteria growth)

Cool then dress wounds dry sterile Pain control as appropriate Prevent hypotension/hypothermia Appropriate hospital destination Hospital communication

Thermal burnsPCP management considerations: Ensure scene safety Remove the patient from the source of the burn ABC’s High flow oxygen Assess for associated injuries Remove clothing and jewelry from burn sites Cool soaks with sterile water

< 20% up to 30 minutes > 20% up to 10 minutes – Major burns no more than 10 minutes

Cover with dry sterile dressings or a clean sheet Watch for and prevent hypothermia Pain management – Entonox (no inhalation injury) Venous access (large bore) – 500 ml NS bolus’ PRN up

to 2 Litres to BP above 90 mmHg

Chemical Burn

PCP management considerations: Paramedic safety - PPE Brush off dry chemical Flush with copious irrigation for 20

minutesPrevent hypothermia

Pain management – Entonox Venous access

Electrical burnsPCP management considerations: Ensure scene is electrically safe Then remove the patient from the electrical

source ABC’s· High flow oxygen· Assess and treat

for associated injuries Moist sterile dressing to burn Pain management – Entonox Venous access (large bore) – 500 ml NS

bolus’ PRN up to 2 Litres to BP above 90 mmHg

Cool Soak Dressing management Skin destruction removes the body's

primary insulation Heat loss can be rapid, especially in

children Cool with tepid isotonic solutions

Cool Major burns no more than 10 minutes

Risk of Hypothermia

Ideal dressing characteristics Sterile Large enough to cover injury Absorbent fluid controlling Lint free Thermal insulation Non adhering Non constricting Allow expansion of underlying tissues

Important emphasis Create a sterile field for dressings Dressing must be loosely applied to protect

the injury from infection and control drainage

Non constricting An inappropriately applied dressing can

increase extent of injury by:Compressing injury

○ Restricting blood flow○ Compartment syndrome○ Tissue hypoxia○ Anaerobic metabolism and acidosis

Summary Do:

Assess the A/W repeatedly, repeatedlyStop the burning processOxygenateKeep the patient warmApply loose dry sterile dressingsGive IV fluidsConsider ALS

Don’t:Don’t pull stuck clothing off the burnDon’t put on ointmentDon’t drown your patientDon’t panic

Thank you

References & Photos○ Emedicine.com○ Tabers Medical Dictionary○ BurnSurgery.org○ HealthCentral.com○ Adam Corporation○ Wikipedia.org○ Emcert.com○ BCAS Protocol Guidelines○ Fastlane.com○ Healthcentral.com