Burns

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

The Skin

Largest Organ in the human Body Sensory Temperature Regulation Barrier vs. Infection and Fluid loss Identification and form

The Skin
Three Basic Layers

The Epidermis : 3 sublayers. The stratum corneum , the squamous layer , and the basal layer , these are the outer layers, providing protection and pigment.
The Dermis: The Layer that contains blood vessels, lymph vessels, Hair follicles, and sweat glands, all held together by COLLIGEN. The subcutaneous layer, AKA the subcutis, forms a network of collagen and fat cells. The subcutis is responsible for conserving the body's heat, while helping to protect the organs of the body from injury by acting as a "shock-absorber".

The Skin

Types of burns

Thermal (Flame, Steam, sunburn, etc.) Chemical (Hydrofluoric Acid, strong alkaline solution) Electrical Radiological

Thermal Burns

Scald

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 area with copious amounts of water.

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.

Electrical Burns

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.

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.

Cold Thermal Injury (Frostbite)

Classification of Burn Injury

Severity is determined by:
depth of burn

extend of burn calculated in percent of total

body surface (TBSA) location of burn patient risk factors

Depth of Burns
Clinical classification

1st degree
Erythema

Super. Dermal

2nd degree

Deep
Dermal

3rd degree

Full Thickness

Extend of Burns

Location of Burns
Vital organs of Face, neck Chest Perineum Hand Joint regions Other areas

burn:

Patient risk factors

Associated trauma Inhalation injuries Circumferential burns Electricity Age (young or old) Pre-existing disease Abuse

1st degree/superficial

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

2nd Degree, Superficial Partial Thickness

Assessing the Burns

2nd Degree Burns AKA Partial Thickness (Deep vs. Superficial) Typically painful unless nerve endings are damaged 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.

2nd Degree, Deep Partial Thickness

3rd degree , Full thickness

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

Assessing the Burns

A common Misconception is that 3rd degree Burns are painless. In reality while 3rd degree burns may be insensate the 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 .

3 Phases of Burn Management

emergent (resuscitative) acute

rehabilitative

Pre-hospital Care

Remove from area! Stop the burn! If thermal burn is large--FOCUS on the ABCs
A=airway-check for patency, soot around nares, or signed nasal hair B=breathing- check for adequacy of ventilation C=circulation-check for presence and regularity of pulses

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

Emergent Phase (Resuscitative Phase)

Lasts from onset to 5 or more days but usually lasts 24-48 hours begins with fluid loss and edema formation and continues until fluid motorization and diuresis begins Greatest initial threat is hypovolemic shock to a major burn patient!

Complications during emergent phase of burn injury are 3 major organ systems...

Cardiovascular
Respiratory Renal systems

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

Parkland Formula for Burns

Fluid Requirements = TBSA burned (%) x Wt (kg) x 4mL Give 1/2 of total requirements in 1st 8 hours, and then give 2nd half over next 16 hours.

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/hr in an adult

Drug Therapy

Analgesics and Sedatives Tetanus immunization Antimicrobial agents: Silver sulfadiazine

Nutritional Therapy
Burn patients need more calories & failure to provide will lead to delayed wound healing and malnutrition.

Clinical Manifestations

Burn wound either heals by primary intention or by grafting. Scars may form & contractures. Mature healing is reached in 6 months to 2 years Avoid direct sunlight for 1 year on burn new skin sensitive to trauma

Complicating or Co-Morbid Factors

Associated Trauma Inhalation Injuries Circumferential Burns Electricity Age (Young or Old) Pre-Existing Disease Abuse

Inhalation Injuries

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 patients should be generally be observed for 24 hours.

Inhalation Injuries

Most fatalities reported at fires are secondary to inhalation injuries CO Binds to Hemoglobin with approx. 100 times stronger bond than does O2 Carboxyhemoglobin levels are found in excess of 50-70% in such patients. Levels of 40-60% may cause mental status changes

Inhalation Injuries

Except for rare events, thermal inhalation injuries are limited to the upper airways When damage does occur, it is often severe enough to cause airway obstructions. This may occur at any time during the resuscitation In the case of hypotension/hypovolemia, the onset of edema may be delayed until perfusion is restored.

Inhalation Injuries
Warning signs can be subtle. Suspicions based on: Hx of event Mental Status Voice Lung sounds Assessment findings Pediatrics are especially high risk secondary to their small airways.

Inhalation Injuries

Early treatment includes high flow O2, Humidified if possible Liberal use of Nasal ETT or RSI and oral ETT placement early in the care plan Aggressive pain control Hyperbaric Chambers are of unproven value.

Electricity

Safety is first. Electrical burns can cause a path of destruction from entrance and exit wounds that may not be readily apparent. Cardiac, Renal, and Electrolyte problems are major concerns. observation is advised.

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)

Circumferential Burns

Circumferential Burns, or near circumferential burns, especially predominately 3rd degree burns, cause swelling to underlying tissues This swelling impairs respiration, circulation and function. This can cause permanent complications and death.

Circumferential Burns

Of Main concern are circumferential burns to the chest. As swelling increases the mechanics of respiration are impaired, the patient will become even more hypoxic and die. This is even more rapid in children who have poor respiratory reserves.

Circumferential Burns

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.

Age (Very Old or Young)

The very old (>55) and the Young (<12) Pts less than 2 have an immature immune system Patients less than 12 have poor respiratory reserves Older patients have degenerative processes that lead to prolonged recover, not accounting for other medical problems All skin can be presumed to be thin in children younger than five years and in adults older than 55 years. It is best to assume that there are no superficial partial thickness burns in these age groups

Pre-Existing Disease

Renal Failure: Even Patients that do not have acute renal failure, but may have risk factor for such, may be thrown into renal failure either by the burn process or by the Hypoperfusion state that develops Hyper K is a risk as well (after 36 hours) Diabetes Cardiac Problems Respiratory problems

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)

Abuse/Intentional Burns

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 body because liquid cools while flowing down - occur usually on front of body

Abuse/Intentional Burns

be suspicious - scald burns on back well defined, uniform 2nd-3rd degree burns on buttocks, extremities immersion burns inflicted maybe as punishment for toileting mishaps may be seen on buttocks on extremities - stocking or glove appearance where feet, hand dipped into hot water

Abuse/Intentional Burns
imprint burns caused by hot object held to skin - like cigarette or curling iron child usually moves away from hot object before receiving serious burns (accidental burn will usually be a single linear mark instead of full imprint which leaves outline - usually found on palm of hand where child grasps hot object) be suspicious - burns on back of hand cigarette burns usually 5-7 mm in diameter, well defined, deep puncture lesion under cigarette burn scab

Referral Criteria
2nd

or 3rd Degree Burns >10% BSA Burns to Face, Hands , Feet, Genitalia, Perineum, or major Joints. ESPECIALY CIRCUMFRENTIAL BURNS Electrical Burns Chemical Burns Inhalation Injury

Referral Criteria

Burns with pre-existing PMHX that could complicate recovery Concomitant trauma (If Major Trauma, The Trauma Center , Not the Burn Center should be the initial stabilizing unit) When in doubt , consult with a burn center

Care of

ABURNS

A- Airway B - breathing U - urine output R - rule of nines resuscitation of fluid N - nutrition S - shock

Escharotomy sites

Questions?