Burns

Sections
Introduction to Burn Injuries Anatomy and Physiology of the Skin Pathophysiology of Burns Assessment of Thermal Burns Management of Thermal Burns Assessment and Management of Electrical, Chemical, and Radiation Burns

Introduction to Burn Injuries

1.25-2 million Americans treated for burns annually
50,000 require hospitalization 3-5% considered life threatening 2nd leading cause of death for children <12 Half of all tap-water burns occur to children <5 Very young & very old Infirm Firefighters Metal smelters Chemical workers

Greatest risk

 Layers

Anatomy & Physiology of the Skin

Epidermis Dermis Subcutaneous Underlying Structures

Fascia Nerves Tendons Ligaments Muscles Organs

 Functions of the Skin

Protection from infection Sensory organ
Temperature Touch Pain

Anatomy & Physiology of the Skin

Controls loss and movement of fluids Temperature regulation Insulation from trauma Flexible to accommodate free body movement

Pathophysiology of Burns Types of Burns

Thermal Electrical Chemical Radiation

Thermal Burns
Heat changes the molecular structure of tissue
Denaturing (of proteins)

Extent of burn damage depends on

Temperature of agent Concentration of heat Duration of contact

Thermal Burns
Jacksons Theory of Thermal Wounds
Zone of Coagulation
Area in a burn nearest the heat source that suffers the most damage as evidenced by clotted blood and thrombosed blood vessels

Zone of Stasis
Area surrounding zone of coagulation characterized by decreased blood flow.

Zone of Hyperemia
Peripheral area around burn that has an increased blood flow.

Jacksons Theory of Thermal Wounds

Zone of Hyperemia

Zone of Stasis

Zone of Coagulation

Bodys Response to Burns Emergent Phase (Stage 1)

Fluid Shift Phase (Stage 2)

Length 18-24 hours Begins after Emergent Phase
Reaches peak in 6-8 hours

Pain response Catecholamine release Tachycardia, Tachypnea, Mild Hypertension, Mild Anxiety

Damaged cells initiate inflammatory response

Increased blood flow to cells Shift of fluid from intravascular to extravascular space
MASSIVE EDEMA Leaky Capillaries

Bodys Response to Burns (Stage 3) Hypermetabolic Phase

Last for days to weeks Large increase in the bodys need for nutrients as it repairs itself

Resolution Phase (Stage 4)

Scar formation General rehabilitation and progression to normal function

Electrical Burns
Terminology
Voltage
Difference of electrical potential between two points Different concentrations of electrons

Amperes
Strength of electrical current

Resistance (Ohms)
Opposition to electrical flow

Electrical Burns
Ohms Law

V = IR
V: Voltage R: Resistance I: Current

V I= R

Based on electron flow thru Tungsten

Emit more light the more current passed thru

Electrical Burns
Joules Law

P =I R
P: Power Skin is resistant to electrical flow
Greater the current the greater the flow thru the body and greater the release of heat

Electrical Burns
Greatest heat occurs at the points of resistance
Entrance and Exit wounds Dry skin = Greater resistance Wet Skin = Less resistance

Longer the contact, the greater the potential of injury Smaller the point of contact, the more concentrated the energy, the greater the injury
Increased damage inside body

Electrical Burns
Electrical Current Flow
Tissue of Less Resistance
Blood vessels Nerve

Tissue of Greater Resistance

Results in
Serious vascular and nervous injury Immobilization of muscles Flash burns

Muscle Bone

Chemical Burns
Chemical destroys tissue
Acids
Form a thick, insoluble mass where they contact tissue. Coagulation necrosis
Limits burn damage

Alkalis
Destroy cell membrane through liquefaction necrosis
Deeper tissue penetration and deeper burns

Radiation Injury
Radiation
Transmission of energy
Nuclear Energy Ultraviolet light Visible Light Heat Sound X-Rays

Radioactive Substance
Emits ionizing radiation Radionuclide or Radioisotope

Radiation Injury Basic Physics

Protons Neutrons
Positive charged particles Equal in mass to protons No electrical charge

Electrons

Minute electrically charged particles When emitted from radioactive substances are termed Beta Particles
(continued)

Radiation Injury Basic Physics

Isotopes
Atoms with unstable nuclear composition
Ionizing Radiation

Half-life
Time required for half the nuclei to lose activity through decay

 Alpha Particles

Radiation Injury Radioactive Substances

Slow moving Low-energy Stopped by clothing and paper Penetrate a few cell layers on skin Minor external hazard HARMFUL if ingested

Beta Particles
Smaller than Alpha Higher energy than alpha Stopped by aluminum or similar materials Less local damage than alpha HARMFUL if inhaled or ingested

Radiation Injury Radioactive Substances Gamma Rays Neutrons

Highly energized Penetrate deeper than Alpha or Beta Most Penetrating than other radiation
3-10 times greater penetration than Gamma EXTREMELY DANGEROUS

Penetrate thick shielding Pass entirely thru clothing, and body

Extensive cell damage

Indirect Damage
Cause internal tissue to emit Alpha and Beta particles

Less internal hazard when ingested than Alpha or Beta Direct tissue damage Only present in Nuclear Reactor Core

LEAD SHIELDING

Radiation Injury Effects on Body

Geiger Counter needed to detect
R/hr: Milliroentgens per hour

RAD

1,000mR = 1R

REM

Radiation absorbed dose of local tissue Roentgen equivalent in man Injury to irradiated part of organism RAD=REM for all purposes

Alters bodys cell DNA Cumulative damage over lifetime exposure Decreased WBCs Acute
Effects in minutes-weeks

Long-Term
Effects years or decades later

Radiation Injury: Safety Clean

TIME
Accident
DISTANCE
Exposed to radiation Not contaminated by products Properly decontaminated

SHEILDING

Dirty Accident
Assoc with Fire at scene of rad. Accident Trained Decon. Personnel

Little danger to personnel

Radiation Injury Management

Park upwind Notify Radiation Response or Haz-Mat Response Team Look for radioactive placards Measure radioactivity Decontaminate patients before care Routine medical care (ABCs, etc)

Inhalation Injury
Toxic Inhalation
Synthetic resin combustion
Cyanide & Hydrogen Sulfide Systemic poisoning More frequent than thermal inhalation burn

Carbon Monoxide Poisoning

Colorless, odorless, tasteless gas Byproduct of incomplete combustion of carbon products
Suspect with faulty heating unit

200x greater affinity for hemoglobin than oxygen

Hypoxemia & Hypercarbia

Inhalation Injury
Airway Thermal Burn
Supraglottic structures absorb heat and prevent lower airway burns
Moist mucosa lining the upper airway

Injury is common from superheated steam Risk Factors

Standing in the burn environment Screaming or yelling in the burn environment Trapped in a closed burn environment

Symptoms
Stridor or Crowing inspiratory sounds Singed facial and nasal hair Black sputum or facial burns Progressive respiratory obstruction and arrest due to swelling

Depth of Burn
Superficial Burn Partial Thickness Burn Full Thickness Burn

Burn Depth
Superficial Burn: 1st Degree Burn
Signs & Symptoms
Reddened skin Pain at burn site Involves only epidermis

Burn Depth
PartialThickness Burn: 2nd Degree Burn
Signs & Symptoms
Intense pain White to red skin Blisters Involves epidermis & dermis

Burn Depth
Full-Thickness Burn: 3rd Degree Burn
Signs & Symptoms
Dry, leathery skin (white, dark brown, or charred) Loss of sensation (little pain) All dermal layers/tissue may be involved

Body Surface Area

Rule of Nines
Best used for large surface areas Expedient tool to measure extent of burn

Rule of Palms
Best used for burns < 10% BSA

Rules of Nines
. .

. .

Rule of Palms
A burn equivalent to the size of the patients hand is equal to 1% body surface area (BSA)

Systemic Complications Hypothermia

Disruption of skin and its ability to thermoregulate

Hypovolemia
Shift in proteins, fluids, and electrolytes to the burned tissue General electrolyte imbalance

Eschar
Hard, leathery product of a deep full thickness burn Dead and denatured skin

Systemic Complications Infection

Greatest risk of burn is infection

Organ Failure
Release of myoglobin

Special Factors
Age & Health

Physical Abuse
Elderly, Infirm or Young

Assessment of Thermal Burns

Scene Size-up
Fire Department
SCBA and protective clothing

Initial Assessment
ABCs MUST be intact
Consider ET or RSI

Rapid evacuation of patient if scene is unstable

Assessment of Thermal Burns

Focused and Rapid Trauma Assessment
Accurately approximate extent of burn injury
Rule of Nines or Rule of Palms Depth of burn Area of body effected
Any burn to the face, hands, feet, joints or genitalia is considered a serious burn

Ringing burns Age of patient affected

Assessment of Thermal Burns

Changes in skin condition at affected site Adventitious sounds Blisters Sloughing of skin Hoarseness Dysphagia Dysphasia

General Signs & Symptoms hair Burnt Pain

Edema Paresthesia Hemorrhage Other soft tissue injury Musculoskeletal injury Dyspnea Chest pain

Assessment of Thermal Burns Burn Severity

Minor
Superficial Partial Thickness Full Thickness <50% BSA <15% BSA <2% BSA >50% BSA >15% BSA >2% BSA >30% BSA

Moderate
Superficial Partial Thickness Full Thickness

Critical
Partial Thickness

Full Thickness Inhalation Injury

>10% BSA

Any partial or full thickness burn involving hands, feet, joints, face, or genitalia

Assessment of Thermal Burns

Ongoing Assessment
Non-critical: Reassess Q 15 min Critical: Reassess Q 5 min

Burn Center Care

Management of Thermal Burns

Local & Minor Burns
Local cooling
Partial thickness: <15% of BSA Full thickness: <2% BSA

Remove clothing Cool or Cold water immersion Consider analgesics

Management of Thermal Burns

Moderate to Severe Burns
Dry sterile dressings
Partial thickness: >15% BSA Full thickness: >5% BSA

Maintain warmth
Prevent hypothermia

Consider aggressive fluid therapy

Moderate to severe burns

Burns over IV sites

Place IV in partial thickness burn site.

Management of Thermal Burns

Parkland Burn Formula
4 mL x Pt wt in kg x % BSA = Amt of fluid
Pt should receive of this amount in first 8 hrs. Remainder in 16 hrs Consider 1 hour dose
0.5ml x Pt wt in kg x % BSA = Amt of fluid

Management of Thermal Burns

Moderate to Severe Burns
Caution for fluid overload
Frequent auscultation of breath sounds

Consider analgesic for pain

Morphine Nubain

Prevent infection

Management of Thermal Burns

Inhalation Injury
Provide high-flow O2 by NRB Consider intubation if swelling Consider hyperbaric oxygen therapy Cyanide Exposure
Sodium Nitrite, Amyl Nitrite, Sodium Thiosulfate
Forms methemoglobin binds to cyanide Non-toxic substance secreted in urine Inhale 1 ampule of Amyl Nitrite 300 mg Sodium Nitrite over 2-4 minutes 12.5 gm of Sodium Thiosulfate

Assessment & Management of Electrical, Chemical & Radiation Burns

Electrical Injuries
Safety
Turn off power Energized lines act as whips Establish a safety zone High voltage, high current, high energy Lasts fraction of a second No danger of electrical shock to EMS

Lightning Strikes

Assessment & Management of Electrical, Chemical & Radiation Burns

Assess patient
Entrance & Exit wounds Remove clothing, jewelry, and leather items Treat any visible injuries
Thermal burns

ECG monitoring
Bradycardia, Tachycardia, VF or Asystole ACLS Protocols Treat cardiac & respiratory arrest Aggressive airway, ventilation, and circulatory management.

Consider Fluid bolus for serious burns

20 ml/kg

Consider Sodium Bicarbonate: 1 mEq/kg Consider Mannitol: 10 g

Assessment & Management of Electrical, Chemical & Radiation Burns

Chemical Burns
Scene size-up
Hazardous materials team Establish hot, warm and cold zones Prevent personnel exposure from chemical Phenol Dry Lime Sodium Riot Control Agents

Specific Chemicals

Assessment & Management of Electrical, Chemical & Radiation Burns

Specific Chemicals
Phenol
Industrial cleaner Alcohol dissolves Phenol Irrigate with copious amounts of water Strong corrosive that reacts with water Brush off dry substance Irrigate with copious amounts of cool water
Prevents reaction with patient tissues

Dry Lime

Assessment & Management of Electrical, Chemical & Radiation Burns

Sodium
Unstable metal Reacts vigorously with water
Releases
Extreme heat Hydrogen gas Ignition

Decontaminate: Brush off dry chemical Cover the wound with oil substance

Assessment & Management of Electrical, Chemical & Radiation Burns

Riot Control Agents
Agents
CS, CN (Mace), Oleoresin, Capsicum (OC, pepper spray)

Irritation of the eyes, mucous membranes, and respiratory tract. No permanent damage General Signs & Symptoms
Coughing, gagging, and vomiting Eye pain, tearing, temporary blindness

Management
Irrigate eyes with normal saline

Assessment & Management of Electrical, Chemical & Radiation Burns

Radiation Burns
Notify Hazardous Materials Team Establish Safety Zones
Hot, Warm, & Cold

Personnel positioned Upwind and Uphill Use older rescuers for recovery Decontaminate ALL rescuers, equipment and patients

Radiation Injury Whole Body Exposure RAD vs. Body Effects (RAD) Effect
5-25 50-75 75-125
125-200 200-600

Asymptomatic Asymptomatic, WBC changes Anorexia, N/V and Fatigue in 2 days N/V, Diarrhea, Anxiety, Tachycardia N/V, Diarrhea, Weakness & Fatigue in Hours 50% Fatal within 6 weeks without Med Care N/V, Diarrhea in hours 100% Fatal within two weeks with Med. Care Burning sensation in minutes, N/V in 10 min Confusion ataxia, Watery Diarrhea in 2 hrs 100% Fatal in short time

6001,000 1,000+

Radiation Injury Local Exposure (RAD) vs Local Effect

(RAD)
50 500 2,500 5,000 50,000 Asymptomatic Asymptomatic (usually), Altered function of exposed area Atrophy, vascular lesion, altered pigment Chronic ulcer, risk of cancer Permanent destruction of exposed tissue

Effect

Assessment & Management of Electrical, Chemical & Radiation Burns

Ongoing assessment
Re-evaluate initial assessment Re-evaluate all interventions