pre hospital burn

8/2/2019 Pre Hospital Burn

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Burns


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Objectives

Understand the basic anatomy and function

of the skin

Identify the types of common burns

Assessment of burn severity

Complications of burn

Immediate care for burn victim


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The Skin

Largest Organ in the human Body

Sensory

Temperature Regulation

Barrier vs. Infection and Fluid loss

Identification and form


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The SkinThree Basic Layers

The Epidermis : 3 sublayers. The stratum corneum ,the squamous layer , and the basal layer , these arethe outer layers, providing protection and pigment.

The Dermis: The Layer that contains blood vessels,lymph vessels, Hair follicles, and sweat glands, allheld together by COLLIGEN.

The subcutaneous layer, AKA the subcutis, forms anetwork of collagen and fat cells. The subcutis isresponsible for conserving the body's heat, whilehelping to protect the organs of the body from injuryby acting as a "shock-absorber".


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The Skin


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Types of burns

Thermal (Flame, Steam, sunburn, etc.)

Chemical (Hydrofluoric Acid, strong

alkaline solution)

Electrical

Radiological


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Thermal Burns


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Scald


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Chemical Burn

examples: cleaning agents...

Remember.

Tissue destruction may continue for up to 72 hours.

It is important to remove the person from the burning agent

or vice versa.The latter is accomplished by irrigate the affected areawith copious amounts of water.


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Smoke and Inhalation Injury

Can damage the tissues of the

respiratory tract

Although damage to the

respiratory mucosa can occur, it

seldom happens because the vocal

cords and glottis closes as a

protective mechanisms.


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Electrical Burns


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Electrical Burns

Injury from electrical burns results from coagulation

necrosis that is caused by intense heat generated from an

electric current.

The severity depends on:

amount of voltage tissue resistance

current pathways

surface area in contact with the current

length of time the current flow.


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Electrical injury can cause:

Fractures of long bones and vertebra

Cardiac arrest or arrhythmias--can be

delayed 24-48 hours after injury

Severe metabolic acidosis--can develop

in minutes

Myoglobinuria--acute renal tubular

necrosis.


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Cold Thermal Injury (Frostbite)


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Depth of Burns

Clinical classification

Erythema

Super.

Dermal

Deep

Dermal

Full

Thickness

1st

degree

2nd

degree

3rd degree


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Extend of Burns


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Location of Burns

Vital organs of burn:

Face, neck

Chest

Perineum

Hand

Joint regions

Other areas


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Patient risk factors

Associated trauma

Inhalation injuries

Circumferential burns

Electricity

Age (young or old)

Pre-existing disease

Abuse


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1st degree/superficial


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Assessing the Burns

1st degree or superficial Burn

Painful, Red, Dry

Blanch with pressure

Pain is the major issue to deal with

E.g. Sunburn, low intensity flash burn


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2nd Degree, Superficial PartialThickness


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Assessing the Burns

2nd Degree Burns AKA Partial Thickness (Deep vs.Superficial)

Typically painful unless nerve endings aredamaged

Blisters,

High Intensity Flash Burns, Hot Grease, Steam

and Flame Infection, swelling, and Pain are primary initial

concerns.

Dehydration may develop over time with large

BSA.


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2nd Degree, Deep PartialThickness


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3rd degree , Full thickness


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Assessing the Burns

3rd degree AKA Full Thickness

May be white and waxen or may be charred

(Eschar).

No sensation is typical,

Cap refill is absent

Primary concerns are infection, pain control

and severe swelling


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Assessing the Burns

A common Misconception is that 3rd degree Burns

are painless.

In reality while 3rd

degree burns may be insensatethe burns are usually surrounded by a Halo of

severe and very painful 2nd degree burned tissue,

known as the Zone of Stasis

This is further complicated by the swelling that

develops with 2nd and 3rd degree burns causing

further pain .


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3 Phases of Burn Management

emergent (resuscitative)acute

rehabilitative


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Pre-hospital Care

Remove from area! Stop the burn!

If thermal burn is large--FOCUS on

the ABCs

A=airway-check for patency, soot aroundnares, or signed nasal hair

B=breathing- check for adequacy ofventilation

C=circulation-check for presence andregularity of pulses


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Other precautions...

Burn too large--dont immerse in water due

to extensive heat loss

Never pack in ice

Pt. should be wrapped in dry clean material

to decrease contamination of wound and

increase warmth


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Emergent Phase (Resuscitative Phase) Lasts from onset to 5 or more days but

usually lasts 24-48 hours

begins with fluid loss and edema formationand continues until fluid motorization and

diuresis begins

Greatest initial threat is hypovolemicshock to a major burn patient!


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Complications during emergent phaseof burn injury are 3 major organ

systems...

CardiovascularRespiratory

Renal systems


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Fluid Therapy

1 or 2 large bore IV lines Fluid replacement based on:

size/depth of burn

age of pt. individualized considerations.

options- RL, NS, Gelafundin, albumin, etc.

there are formulas for replacement: Parkland formula

Brooke formula


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Parkland Formula for Burns

Fluid Requirements = TBSA burned (%) xWt (kg) x 4mL

Give 1/2 of total requirements in 1st 8

hours, and then give 2nd half over next 16hours.


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Assessment of adequacy of fluid replacement

Urine output is most commonly used parameter

Urine osmolarity is the most accurate parameter

Urine output= 30-50 ml/hrin an adult


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Drug Therapy

Analgesics and Sedatives Tetanus immunization

Antimicrobial agents: Silver sulfadiazine

Nutritional Therapy

Burn patients need more calories & failure toprovide will lead to delayed wound healing and

malnutrition.


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Clinical Manifestations

Burn wound either heals byprimary intention or by grafting.

Scars may form & contractures. Mature healing is reached in 6

months to 2 years

Avoid direct sunlight for 1 yearon burn

new skin sensitive to trauma


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Complicating or Co-Morbid

Factors Associated Trauma

Inhalation Injuries

Circumferential Burns

Electricity

Age (Young or Old)

Pre-Existing Disease

Abuse


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Inhalation Injuries


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Inhalation Injuries

Three basic Types of inhalation Injury

CO Poisoning

Injury above the Glottis Injury Below the glottis

Onset of S/S of inhalation injury in

unpredictable enough that these patientsshould be generally be observed for 24hours.


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Inhalation Injuries

Most fatalities reported at fires aresecondary to inhalation injuries

CO Binds to Hemoglobin with approx. 100times stronger bond than does O2

Carboxyhemoglobin levels are found inexcess of 50-70% in such patients.

Levels of 40-60% may cause mental statuschanges


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Inhalation Injuries

Except for rare events, thermal inhalation injuriesare limited to the upper airways

When damage does occur, it is often severeenough to cause airway obstructions.

This may occur at any time during theresuscitation

In the case of hypotension/hypovolemia, the onsetof edema may be delayed until perfusion isrestored.


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Inhalation Injuries

Warning signs can be subtle. Suspicions basedon:

Hx of event

Mental Status

Voice

Lung sounds

Assessment findings Pediatrics are especially high risk secondary to

their small airways.


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Inhalation Injuries

Early treatment includes high flow O2,

Humidified if possible

Liberal use of Nasal ETT or RSI and oralETT placement early in the care plan

Aggressive pain control

Hyperbaric Chambers are of unprovenvalue.


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Electricity

Safety is first.

Electrical burns can cause a path of

destruction from entrance and exit woundsthat may not be readily apparent.

Cardiac, Renal, and Electrolyte problems

are major concerns. observation is advised.


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Chemical Burns

May cause problems unrelated to the burns

(Hydrofluoric Acid)

May be difficult to stop the burning process(Chlorine Gas=Hydrochloric Acid)

May have to chose between the lesser of

two evils (Rapid decon vs. Treatment,Bicarb nebs, etc)


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Circumferential Burns, or nearcircumferential burns, especially

predominately 3rd

degree burns, causeswelling to underlying tissues

This swelling impairs respiration,circulation and function.

This can cause permanent complicationsand death.


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Of Main concern are circumferential burns

to the chest.

As swelling increases the mechanics ofrespiration are impaired, the patient will

become even more hypoxic and die.

This is even more rapid in children whohave poor respiratory reserves.


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Treatment is an Emergent Pre-Hospital

Escharotomy

This should be done after Pneumothorax,ETT/D.O.P. E. , and other issues are

considered, however the progression to this

treatment should be rapid.


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Age (Very Old or Young)

The very old (>55) and the Young (


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Pre-Existing Disease Renal Failure: Even Patients that do not have

acute renal failure, but may have risk factor forsuch, may be thrown into renal failure either bythe burn process or by the Hypoperfusion state

that develops Hyper K is a risk as well (after 36 hours)

Diabetes

Cardiac Problems

Respiratory problems


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Abuse/Intentional Burns

May be young, Old , or the disabled. May be domestic in

nature.

Suspected abuse patients should be transported when ever

possible

Document thoroughly but objectively

Do not press to hard , the important thing is to get the

patient to the hospital, be careful not to prompt a refusal

Be aware of psychological issues and act accordingly

Be aware that some of these injuries may be cultural in

nature (cupping, coining)


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burns

scalding (most common burn injury)

range from first to third degree in severity usually include splash burns

accidental burns from hot, liquid spills usually

more severe on upper body than lower bodybecause liquid cools while flowing down - occur

usually on front of body


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be suspicious - scald burns on back well defined,uniform 2nd-3rd degree burns on buttocks,extremities

immersion burns

inflicted maybe as punishment for toiletingmishaps

may be seen on buttocks on extremities - stocking or glove appearance

where feet, hand dipped into hot water


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imprint burns caused by hot object held to skin - like

cigarette or curling iron

child usually moves away from hot objectbefore receiving serious burns (accidental burn

will usually be a single linear mark instead offull imprint which leaves outline - usuallyfound on palm of hand where child grasps hotobject)

be suspicious - burns on back of hand

cigarette burns usually 5-7 mm in diameter,well defined, deep puncture lesion undercigarette burn scab


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Referral Criteria

2nd or 3rd Degree Burns >10% BSA

Burns to Face, Hands , Feet, Genitalia,

Perineum, or major Joints. ESPECIALYCIRCUMFRENTIAL BURNS

Electrical Burns

Chemical Burns

Inhalation Injury


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Referral Criteria

Burns with pre-existing PMHX that could

complicate recovery

Concomitant trauma (If Major Trauma, TheTrauma Center , Not the Burn Center

should be the initial stabilizing unit)

When in doubt , consult with a burn center


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Care of A B U R N S

A- Airway

B - breathing

U - urine outputR - rule of nines

resuscitation of fluid

N - nutritionS - shock

Escharotomy sites


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Escharotomy sites


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pre hospital burn

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