brest ppt
TRANSCRIPT
Burn InjuriesBurn Injuries
EMS ProfessionsEMS Professions
Temple CollegeTemple College
EpidemiologyEpidemiology Tissue injury caused by thermal, Tissue injury caused by thermal,
electrical, or chemical agentselectrical, or chemical agents Can be fatal, disfiguring, or Can be fatal, disfiguring, or
incapacitatingincapacitating ~ 1.25 million burn injuries per year~ 1.25 million burn injuries per year
• 45,000 hospitalized per year45,000 hospitalized per year• 4500 die per year (3750 from housefires)4500 die per year (3750 from housefires)
3rd largest cause of accidental death 3rd largest cause of accidental death
Risk FactorsRisk Factors
Fire/CombustionFire/Combustion• FirefighterFirefighter• Industrial WorkerIndustrial Worker• Occupant of burning structuresOccupant of burning structures
Chemical ExposureChemical Exposure• Industrial WorkerIndustrial Worker
Electrical ExposureElectrical Exposure• ElectricianElectrician• Electrical Power Distribution WorkerElectrical Power Distribution Worker
Anatomy and Physiology Anatomy and Physiology of Skinof Skin
SkinSkin
Largest body organ. Much more Largest body organ. Much more than a passive organ.than a passive organ.• Protects underlying tissues from injuryProtects underlying tissues from injury• Temperature regulationTemperature regulation• Acts as water tight seal, keeping body Acts as water tight seal, keeping body
fluids influids in• Sensory organSensory organ
SkinSkin
Injuries to skin which result in loss, Injuries to skin which result in loss, have problems with:have problems with:• InfectionInfection• Inability to maintain normal water Inability to maintain normal water
balancebalance• Inability to maintain body temperatureInability to maintain body temperature
SkinSkin
Two layersTwo layers• EpidermisEpidermis• DermisDermis
EpidermisEpidermis• Outer cells are Outer cells are
deaddead• Act as protection Act as protection
and form water and form water tight sealtight seal
SkinSkin
EpidermisEpidermis• Deeper layers divide to produce the Deeper layers divide to produce the
stratum corneum and also contain stratum corneum and also contain pigment to protect against UV pigment to protect against UV radiationradiation
DermisDermis• Consists of tough, elastic connective Consists of tough, elastic connective
tissue which contains specialized tissue which contains specialized structuresstructures
Skin Skin
Dermis - Specialized StructuresDermis - Specialized Structures• Nerve endingsNerve endings• Blood vesselsBlood vessels• Sweat glandsSweat glands• Oil glands - keep skin waterproof, Oil glands - keep skin waterproof,
usually discharges around hair shaftsusually discharges around hair shafts• Hair follicles - produce hair from hair Hair follicles - produce hair from hair
root or papillaroot or papilla– Each follicle has a small muscle (arrectus pillorum) which can Each follicle has a small muscle (arrectus pillorum) which can
pull the hair upright and cause goose fleshpull the hair upright and cause goose flesh
Burn InjuriesBurn Injuries
Burn InjuriesBurn Injuries
Potential complicationsPotential complications• Fluid and Electrolyte loss Fluid and Electrolyte loss
HypovolemiaHypovolemia• Hypothermia, Infection, AcidosisHypothermia, Infection, Acidosis catecholamine release, catecholamine release,
vasoconstrictionvasoconstriction• Renal or hepatic failureRenal or hepatic failure• Formation of escharFormation of eschar• Complications of circumferential burnComplications of circumferential burn
Burn InjuriesBurn Injuries
An important step in management An important step in management is to determine depth and extent of is to determine depth and extent of damage to determine where and damage to determine where and how the patient should be treatedhow the patient should be treated
Types of Burn InjuriesTypes of Burn Injuries Thermal burnThermal burn
• Skin injurySkin injury• Inhalation injuryInhalation injury
Chemical burnChemical burn• Skin injurySkin injury• Inhalation injuryInhalation injury• Mucous membrane injuryMucous membrane injury
Electrical burnElectrical burn• LightningLightning
Radiation burnRadiation burn
Depth ClassificationDepth Classification
SuperficialSuperficial Partial thicknessPartial thickness Full thicknessFull thickness
Burn ClassificationsBurn Classifications
1st degree (Superficial burn)1st degree (Superficial burn)• Involves the epidermisInvolves the epidermis• Characterized by reddeningCharacterized by reddening• Tenderness and PainTenderness and Pain• Increased warmthIncreased warmth• Edema may occur, but no blisteringEdema may occur, but no blistering• Burn blanches under pressureBurn blanches under pressure• Example - sunburnExample - sunburn• Usually heal in ~ 7 daysUsually heal in ~ 7 days
Burn ClassificationsBurn Classifications
First Degree BurnFirst Degree Burn(Superficial Burn)(Superficial Burn)
Burn ClassificationsBurn Classifications
2nd degree2nd degree• Damage extends through the epidermis Damage extends through the epidermis
and involves the dermis.and involves the dermis.• Not enough to interfere with Not enough to interfere with
regeneration of the epitheliumregeneration of the epithelium• Moist, shiny appearanceMoist, shiny appearance• Salmon pink to red colorSalmon pink to red color• PainfulPainful• Does not have to blister to be 2nd degreeDoes not have to blister to be 2nd degree• Usually heal in ~7-21 daysUsually heal in ~7-21 days
Burn ClassificationsBurn Classifications
2nd Degree 2nd Degree BurnBurn(Partial (Partial Thickness Thickness Burn)Burn)
Burn ClassificationsBurn Classifications
3rd degree3rd degree• Both epidermis and dermis are destroyed Both epidermis and dermis are destroyed
with burning into SQ fatwith burning into SQ fat• Thick, dry appearanceThick, dry appearance• Pearly gray or charred black colorPearly gray or charred black color• Painless - nerve endings are destroyedPainless - nerve endings are destroyed• Pain is due to intermixing of 2nd degreePain is due to intermixing of 2nd degree• May be minor bleedingMay be minor bleeding• Cannot heal and require graftingCannot heal and require grafting
Burn ClassificationsBurn Classifications
3rd Degree Burn3rd Degree Burn(Full Thickness (Full Thickness burn)burn)
Burn InjuriesBurn Injuries
Often it is not possible to predict Often it is not possible to predict the exact depth of a burn in the the exact depth of a burn in the acute phase. Some 2nd degree acute phase. Some 2nd degree burns will convert to 3rd when burns will convert to 3rd when infection sets in. When in doubt infection sets in. When in doubt call it 3rd degree.call it 3rd degree.
Body Surface Area Body Surface Area EstimationEstimation
Rule of Rule of NinesNines• AdultAdult
Palm Palm RuleRule
Body Surface Area Body Surface Area EstimationEstimation
Rule of Rule of NinesNines• PedsPeds
– For each yr For each yr over 1 yoa, over 1 yoa, subtract 1% subtract 1% from head and from head and add equally to add equally to legslegs
Palm RulePalm Rule
Burn Patient SeverityBurn Patient Severity
Factors to ConsiderFactors to Consider• Depth or ClassificationDepth or Classification• Body Surface area burnedBody Surface area burned• Age: Adult vs PediatricAge: Adult vs Pediatric• Preexisting medical conditionsPreexisting medical conditions• Associated TraumaAssociated Trauma
– blast injury blast injury
– fall injuryfall injury
– airway compromiseairway compromise
– child abusechild abuse
Burn Patient SeverityBurn Patient Severity
Patient agePatient age• Less than 2 or greater than 55Less than 2 or greater than 55• Have increased incidence of complicationHave increased incidence of complication
Burn configurationBurn configuration• Circumferential burns can cause total Circumferential burns can cause total
occlusion of circulation to an area due to occlusion of circulation to an area due to edemaedema
• Restrict ventilation if encircle the chestRestrict ventilation if encircle the chest• Burns on joint area can cause disability due to Burns on joint area can cause disability due to
scar formationscar formation
Critical Burn CriteriaCritical Burn Criteria
330 0 > 10% BSA> 10% BSA 2200 > 30% BSA > 30% BSA
• >20% pediatric>20% pediatric Burns with respiratory injuryBurns with respiratory injury Hands, face, feet, or genitaliaHands, face, feet, or genitalia Burns complicated by other traumaBurns complicated by other trauma Underlying health problemsUnderlying health problems Electrical and deep chemical burns Electrical and deep chemical burns
Moderate Burn CriteriaModerate Burn Criteria
3300 2-10% BSA 2-10% BSA 2200 15-30% BSA 15-30% BSA
• 10-20% pediatric10-20% pediatric Excluding hands, face, feet, or Excluding hands, face, feet, or
genitaliagenitalia Without complicating factorsWithout complicating factors
Minor Burn CriteriaMinor Burn Criteria
3300 < 2% BSA < 2% BSA 2200 < 15% BSA < 15% BSA
• <10% pediatric<10% pediatric 1100 < 20% BSA < 20% BSA
Thermal Burn Injury Thermal Burn Injury PathophysiologyPathophysiology
Emergent phaseEmergent phase• Response to pain Response to pain catecholamine release catecholamine release
Fluid shift phaseFluid shift phase• massive shift of fluid - intravascular massive shift of fluid - intravascular
extravascularextravascular Hypermetabolic phaseHypermetabolic phase
demand for nutrients demand for nutrients repair tissue repair tissue damagedamage
Resolution phaseResolution phase• scar tissue and remodeling of tissuescar tissue and remodeling of tissue
Thermal Burn Injury Thermal Burn Injury PathophysiologyPathophysiology
Jackson’s Thermal Wound TheoryJackson’s Thermal Wound Theory• Zone of CoagulationZone of Coagulation
– area nearest burn area nearest burn
– cell membranes rupture, clotted blood and thrombosed vesselscell membranes rupture, clotted blood and thrombosed vessels
• Zone of StasisZone of Stasis– area surrounding zone of coagulation area surrounding zone of coagulation
– inflammation, decreased blood flowinflammation, decreased blood flow
• Zone of HyperemiaZone of Hyperemia– peripheral area of burnperipheral area of burn
– limited inflammation, increased blood flowlimited inflammation, increased blood flow
Thermal Burn Injury Thermal Burn Injury PathophysiologyPathophysiology
Eschar formationEschar formation• Skin denaturingSkin denaturing
– hard and leatheryhard and leathery
• Skin constricts over woundSkin constricts over wound– increased pressure underneathincreased pressure underneath
– restricts blood flowrestricts blood flow
• Respiratory compromiseRespiratory compromise– secondary to circumferential eschar around the thoraxsecondary to circumferential eschar around the thorax
• Circulatory compromiseCirculatory compromise– secondary to circumferential eschar around extremitysecondary to circumferential eschar around extremity
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury Remove to safe area, if possibleRemove to safe area, if possible Stop the burning processStop the burning process
• Extinguish fire - cool smoldering areasExtinguish fire - cool smoldering areas• Remove clothing and jewelryRemove clothing and jewelry• Cut around areas where clothing is Cut around areas where clothing is
stuck to skinstuck to skin• Cool adherent substances (Tar, Plastic)Cool adherent substances (Tar, Plastic)
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury
Pertinent HistoryPertinent History• How long ago?How long ago?• What care has been given?What care has been given?• What burned with?What burned with?• Burned in closed space?Burned in closed space?
– Products of combustion present?Products of combustion present?
– How long exposed?How long exposed?
– Loss of consciousness?Loss of consciousness?
• Past medical history?Past medical history?
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury Airway and BreathingAirway and Breathing
• Assess for potential airway involvementAssess for potential airway involvement– soot or singing involving mouth, nose, hair, face, facial hairsoot or singing involving mouth, nose, hair, face, facial hair– coughing, black sputumcoughing, black sputum– enclosed fire environmentenclosed fire environment
• Assist ventilations as neededAssist ventilations as needed• 100% oxygen via NRB if:100% oxygen via NRB if:
– Moderate or critical burnModerate or critical burn– Patient unconsciousPatient unconscious– Signs of possible airway burn/inhalation injurySigns of possible airway burn/inhalation injury– History of exposure to carbon monoxide or smokeHistory of exposure to carbon monoxide or smoke
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury Airway and Breathing (cont)Airway and Breathing (cont)
• Respiratory rates are unreliable due to Respiratory rates are unreliable due to toxic combustion product’stoxic combustion product’s
– May cause depressant effectsMay cause depressant effects
• Be prepared to intubate early if patient Be prepared to intubate early if patient has inhalation injurieshas inhalation injuries
– Prep early for RSIPrep early for RSI
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury Circulatory StatusCirculatory Status
• Burns do not cause rapid onset of Burns do not cause rapid onset of hypovolemic shockhypovolemic shock
• If shock is present, look for other If shock is present, look for other injuriesinjuries
• Circumferential burns may cause Circumferential burns may cause decreased perfusion to extremitydecreased perfusion to extremity
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury
OtherOther• Assess Burn Surface Area & Associated Assess Burn Surface Area & Associated
InjuriesInjuries• AnalgesiaAnalgesia• Avoid topical agents except as directed Avoid topical agents except as directed
by local burn centersby local burn centers– e.g. silvadenee.g. silvadene
• Fluid TherapyFluid Therapy
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury
Consider Fluid Therapy forConsider Fluid Therapy for• >10% BSA 3>10% BSA 300
• >15% BSA 2>15% BSA 200
• >30-50% BSA 1>30-50% BSA 100 with accompanying 2 with accompanying 20 0
LR using Parkland Burn FormulaLR using Parkland Burn Formula• 4 (2-4) cc/kg/% burn4 (2-4) cc/kg/% burn• 1/2 in first 8 hours1/2 in first 8 hours• 1/2 over 2nd 16 hours1/2 over 2nd 16 hours
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury
Fluid therapyFluid therapy• ObjectiveObjective
– HR < 110/minuteHR < 110/minute
– Normal sensorium (awake, alert, oriented)Normal sensorium (awake, alert, oriented)
– Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi)Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi)
– Resuscitation formula’s provide estimates, adjust to individual Resuscitation formula’s provide estimates, adjust to individual patient responsespatient responses
• Start through burn if necessary, upper Start through burn if necessary, upper extremities preferredextremities preferred
• Monitor for Pulmonary EdemaMonitor for Pulmonary Edema
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury
AnalgesiaAnalgesia• Morphine SulfateMorphine Sulfate
– 2-3 mg repeated q 10 minutes titrated to adequate ventilations 2-3 mg repeated q 10 minutes titrated to adequate ventilations and blood pressureand blood pressure
– 0.1 mg/kg for pediatric0.1 mg/kg for pediatric
– May require large but tolerable total dosesMay require large but tolerable total doses
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury
Treat Burn Wound Treat Burn Wound • Low priority - After ABC’s and initiation Low priority - After ABC’s and initiation
of IV’sof IV’s• Do not rupture blistersDo not rupture blisters• Cover with sterile dressingsCover with sterile dressings
– Moist: Controversial, limit to small areas (<10%) or limit time of Moist: Controversial, limit to small areas (<10%) or limit time of applicationapplication
– Dry: Use for larger areas due to concern for hypothermiaDry: Use for larger areas due to concern for hypothermia
– Cover with burn sheetCover with burn sheet
• No “Goo” on burn unless directed by No “Goo” on burn unless directed by burn centerburn center
Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury
Transport ConsiderationsTransport Considerations• Appropriate FacilityAppropriate Facility
– Burn Center or NotBurn Center or Not
• Factor to considerFactor to consider– Burn Patient Severity CriteriaBurn Patient Severity Criteria
– Critical, Moderate, Minor Burn CriteriaCritical, Moderate, Minor Burn Criteria
– Confounding factorsConfounding factors
– Transport resourcesTransport resources
Inhalation InjuryInhalation Injury
Anticipate respiratory problems:Anticipate respiratory problems:• Head, Face, Neck or ChestHead, Face, Neck or Chest• Nasal or eyebrow hairs are singedNasal or eyebrow hairs are singed• Hoarseness, tachypnea, drooling presentHoarseness, tachypnea, drooling present• Loss of consciousness in burned areaLoss of consciousness in burned area• Nasal/Oral mucosa red or dryNasal/Oral mucosa red or dry• Soot in mouth or noseSoot in mouth or nose• Coughing up black sputumCoughing up black sputum• In enclosed burning area (e.g. small In enclosed burning area (e.g. small
apartment)apartment)
Inhalation InjuryInhalation Injury
Burned or exposed to products of Burned or exposed to products of combustion in closed spacecombustion in closed space
Cough present, especially if Cough present, especially if productive of carbonaceous sputumproductive of carbonaceous sputum
Any patient in fire has potential of Any patient in fire has potential of hypoxia and Carbon monoxide hypoxia and Carbon monoxide poisoningpoisoning
Inhalation Injury Inhalation Injury
Supraglottic InjurySupraglottic Injury• Susceptible to injury from high Susceptible to injury from high
temperaturestemperatures• May result in immediate edema of May result in immediate edema of
pharynx and larynxpharynx and larynx– Brassy coughBrassy cough
– StridorStridor
– HoarsenessHoarseness
– Carbonaceous sputumCarbonaceous sputum
– Facial burnsFacial burns
Inhalation Injury Inhalation Injury
Subglottic InjurySubglottic Injury• Rare injuryRare injury• Injury to Lung parenchymaInjury to Lung parenchyma• Usually due to superheated steam, Usually due to superheated steam,
aspiration of scalding liquid, or aspiration of scalding liquid, or inhalation of toxic chemicalsinhalation of toxic chemicals
• May be immediate but usually delayedMay be immediate but usually delayed– Wheezing or CracklesWheezing or Crackles
– Productive coughProductive cough
– BronchospasmBronchospasm
Inhalation injuryInhalation injury
Other ConsiderationsOther Considerations• Toxic gas inhalationToxic gas inhalation• Smoke inhalationSmoke inhalation• Carbon Monoxide poisoningCarbon Monoxide poisoning• Thiocyanate poisoningThiocyanate poisoning• Thermal burnsThermal burns• Chemical burnsChemical burns
Inhalation Injury Inhalation Injury ManagementManagement
Airway, Oxygenation and VentilationAirway, Oxygenation and Ventilation• Assess for airway edema early and oftenAssess for airway edema early and often• Consider early intubation, RSIConsider early intubation, RSI• When in doubt oxygenate and ventilateWhen in doubt oxygenate and ventilate• High flow oxygenHigh flow oxygen• Bronchodilators may be considered if Bronchodilators may be considered if
bronchospasm presentbronchospasm present• Diuretics not appropriate for pulmonary Diuretics not appropriate for pulmonary
edemaedema
Inhalation Injury Inhalation Injury ManagementManagement
CirculationCirculation• Treat for Shock (rare)Treat for Shock (rare)• IV AccessIV Access
– LR/NS large bore, multiple IVsLR/NS large bore, multiple IVs
– Titrate fluids to maintain systolic BP and perfusionTitrate fluids to maintain systolic BP and perfusion
• Avoid MAST/PASGAvoid MAST/PASG
Inhalation Injury Inhalation Injury ManagementManagement
Other ConsiderationsOther Considerations• Assess for other Burns and InjuriesAssess for other Burns and Injuries• Treat burn soft tissue injuryTreat burn soft tissue injury• Treat associated inhalation injury/poisoningTreat associated inhalation injury/poisoning
– Cyanide poisoning antidote kitCyanide poisoning antidote kit– Positive pressure ventilationPositive pressure ventilation– Hyperbaric chamber (carbon monoxide poisoning)Hyperbaric chamber (carbon monoxide poisoning)
Transport considerationsTransport considerations• Burn CenterBurn Center• Hyperbaric chamberHyperbaric chamber
Chemical BurnsChemical Burns
Usually associated with industrial Usually associated with industrial exposureexposure
First Consideration: Should you be First Consideration: Should you be here?here?• Does the patient need decontamination Does the patient need decontamination
before treatment?before treatment? Burning will continue as long as the Burning will continue as long as the
chemical is on the skinchemical is on the skin
Chemical BurnsChemical Burns
AcidsAcids• Immediate coagulation-type necrosis Immediate coagulation-type necrosis
creating an eschar though self-limiting creating an eschar though self-limiting injuryinjury
– coagulation of protein results in necrosis in which affected coagulation of protein results in necrosis in which affected cells or tissue are converted into a dry, dull, homogeneous cells or tissue are converted into a dry, dull, homogeneous eosinophilic mass without nucleieosinophilic mass without nuclei
Chemical BurnsChemical Burns
Bases (Alkali)Bases (Alkali)• Liquefactive necrosis with continued Liquefactive necrosis with continued
penetration into deeper tissue penetration into deeper tissue resulting in extensive injuryresulting in extensive injury
– characterized by dull, opaque, partly or completely fluid characterized by dull, opaque, partly or completely fluid remains of tissueremains of tissue
Dry ChemicalsDry Chemicals• Exothermic reaction with waterExothermic reaction with water
Chemical Burn Chemical Burn ManagementManagement
Definitive treatment is to get the Definitive treatment is to get the chemical off!chemical off!
Begin washing immediately - Begin washing immediately - removal the patient’s clothing as removal the patient’s clothing as you washyou wash• Watch for the socks and shoes, they Watch for the socks and shoes, they
trap chemicalstrap chemicals
Chemical Burn Chemical Burn ManagementManagement
Liquid ChemicalsLiquid Chemicals• wash off with copious amounts of fluidwash off with copious amounts of fluid
Dry ChemicalsDry Chemicals• brush away as much of the chemicals brush away as much of the chemicals
as possibleas possible• then wash off with large quantities of then wash off with large quantities of
water water Flush for 20-30 minutes to remove Flush for 20-30 minutes to remove
all chemicalsall chemicals
Chemical Burn Chemical Burn ManagementManagement
Do not attempt neutralizationDo not attempt neutralization• can cause additional chemical or can cause additional chemical or
thermal burns from the heat of thermal burns from the heat of neutralizationneutralization
Assess and Deliver secondary care Assess and Deliver secondary care as with other thermal and as with other thermal and inhalation burnsinhalation burns
Chemical Burn to Eye Chemical Burn to Eye ManagementManagement Flood the eye with copious Flood the eye with copious
amounts of water amounts of water onlyonly• Never place chemical antidote in eyesNever place chemical antidote in eyes
Flush using LR/NS/HFlush using LR/NS/H22O from medial O from medial to lateral for at least 15 minutesto lateral for at least 15 minutes• Nasal CannulaNasal Cannula• IV Ad SetIV Ad Set
Remove contact lensesRemove contact lenses• May trap irritantsMay trap irritants
Specific Chemical Specific Chemical ConsiderationsConsiderations Dry limeDry lime
• Brush offBrush off• Dry lime is water activatedDry lime is water activated• Then flush with copious amounts of waterThen flush with copious amounts of water
PhenolPhenol• Not water solubleNot water soluble• If available, use alcohol before flushing If available, use alcohol before flushing
except in eyesexcept in eyes• If unavailable, use copious amounts of If unavailable, use copious amounts of
waterwater
Specific Chemical Specific Chemical ConsiderationsConsiderations
Sodium/Potassium metalsSodium/Potassium metals• Reacts violently on contact with HReacts violently on contact with H2200
• Requires large amounts of waterRequires large amounts of water Sulfuric AcidSulfuric Acid
• Generates heat on exposure to H2O (exothermic)Generates heat on exposure to H2O (exothermic)• Wash with soap to neutralize or use copious Wash with soap to neutralize or use copious
amounts Hamounts H22OO
Tar BurnsTar Burns• Use cold packsUse cold packs• Do not pull off, can be dissolved laterDo not pull off, can be dissolved later
Specific Chemical Specific Chemical ConsiderationsConsiderations Chemical MaceChemical Mace
• CN or CSCN or CS– First chemical agents used by police/militaryFirst chemical agents used by police/military
• Mucous membrane and respiratory tract Mucous membrane and respiratory tract irritantirritant
• Skin sensitizerSkin sensitizer• ManagementManagement
– Treat respiratory distressTreat respiratory distress
– Continued irrigation and shower decontaminationContinued irrigation and shower decontamination
– Protect yourself firstProtect yourself first
– Decontaminate everything afterwardDecontaminate everything afterward
Specific Chemical Specific Chemical ConsiderationsConsiderations
Chemical MaceChemical Mace• OCOC
– Commonly referred to as “pepper spray”Commonly referred to as “pepper spray”
• Not as toxic as CN or CSNot as toxic as CN or CS• Mucous membrane irritant and skin Mucous membrane irritant and skin
sensitizersensitizer• May cause respiratory irritationMay cause respiratory irritation• ManagementManagement
– Treat respiratory distressTreat respiratory distress– Continued irrigation and shower decontaminationContinued irrigation and shower decontamination– Protect yourself firstProtect yourself first– Decontaminate everything afterwardDecontaminate everything afterward
Electrical BurnsElectrical Burns
Usually follows accidental contact Usually follows accidental contact with exposed object conducting with exposed object conducting electricityelectricity• Electrically powered devicesElectrically powered devices• Electrical wiringElectrical wiring• Power transmission linesPower transmission lines
Can also result from LightningCan also result from Lightning Damage depends on intensity of Damage depends on intensity of
currentcurrent
Electrical BurnsElectrical Burns Current kills, voltage simply determines Current kills, voltage simply determines
whether current can enter the bodywhether current can enter the body• Ohm’s law: I=V/ROhm’s law: I=V/R
Electrical follows shortest path to Electrical follows shortest path to groundground
Low VoltageLow Voltage• usually cannot enter body unless:usually cannot enter body unless:
– Skin is broken or moistSkin is broken or moist
– Low Resistance (follows blood vessels/nerves)Low Resistance (follows blood vessels/nerves)
High VoltageHigh Voltage• easily overcomes resistanceeasily overcomes resistance
Electrical BurnsElectrical Burns
Severity depends upon:Severity depends upon:• what tissue current passes throughwhat tissue current passes through• width or extent of the current pathwaywidth or extent of the current pathway• AC or DCAC or DC• duration of current contactduration of current contact
Electrical BurnsElectrical Burns
Most damage done is due to heat Most damage done is due to heat produced as current flows through produced as current flows through tissuestissues
Skin burns where current enters Skin burns where current enters and leaves can be almost trivial and leaves can be almost trivial lookinglooking• Everything between can be cookedEverything between can be cooked
Higher voltage may result in more Higher voltage may result in more obvious external burnsobvious external burns
Electrical BurnsElectrical Burns
Alternating Current (AC)Alternating Current (AC)• Tetanic muscle contraction may occur Tetanic muscle contraction may occur
resulting in:resulting in:– Muscle injuryMuscle injury
– Tendon RuptureTendon Rupture
– Joint DislocationJoint Dislocation
– FracturesFractures
• Spasms may keep patient from freeing Spasms may keep patient from freeing oneself from currentoneself from current
Electrical BurnsElectrical Burns
Contact with Alternating Current Contact with Alternating Current can also result in:can also result in:• Cardiac arrhythmiasCardiac arrhythmias• Apnea Apnea • SeizuresSeizures
Electrical BurnsElectrical Burns
In addition to contact burns, In addition to contact burns, patients can also develop flash patients can also develop flash burns when the current arcs near burns when the current arcs near themthem• Flame burns may occur when clothing Flame burns may occur when clothing
ignites after exposure to electrical ignites after exposure to electrical currentcurrent
Electrical BurnsElectrical Burns
LightningLightning• HIGH VOLTAGE!!!HIGH VOLTAGE!!!• Injury may result fromInjury may result from
– Direct StrikeDirect Strike
– Side FlashSide Flash
• Severe injuries often resultSevere injuries often result• Provides additional risk to EMS Provides additional risk to EMS
providerprovider– Weather capable of producing lightning is still in the areaWeather capable of producing lightning is still in the area
Electrical BurnsElectrical Burns
Pathophysiology of InjuriesPathophysiology of Injuries• External BurnExternal Burn• Internal BurnInternal Burn• Musculoskeletal injuryMusculoskeletal injury• Cardiovascular injuryCardiovascular injury• Respiratory injuryRespiratory injury• Neurologic injuryNeurologic injury• Rhabdomyolysis and Renal injuryRhabdomyolysis and Renal injury
Electrical Burn Electrical Burn ManagementManagement
Make sure current is offMake sure current is off• Lightning hazardsLightning hazards• Do not go near patient until current is Do not go near patient until current is
offoff ABC’sABC’s
• Ventilate and perform CPR as neededVentilate and perform CPR as needed• OxygenOxygen• ECG monitoringECG monitoring
– Treat dysrhythmiasTreat dysrhythmias
Electrical Burn Electrical Burn ManagementManagement
Rhabdomyolysis ConsiderationsRhabdomyolysis Considerations• Fluid?Fluid?• Dopamine?Dopamine?
Assess for additional injuriesAssess for additional injuries Consider transport to trauma Consider transport to trauma
centercenter
Electrical Burn Electrical Burn ManagementManagement
Any patient with an electrical Any patient with an electrical burnburn regardless of how trivial it looks regardless of how trivial it looks needs to go to the hospital. There is needs to go to the hospital. There is no way to tell how bad the burn is no way to tell how bad the burn is on the inside by the way it looks on on the inside by the way it looks on the outside.the outside.
Radiation ExposureRadiation Exposure
Waves or particles of energy that are Waves or particles of energy that are emitted from radioactive sourcesemitted from radioactive sources• Alpha radiationAlpha radiation
– large, travel a short distance, minimal penetrating abilitylarge, travel a short distance, minimal penetrating ability– can harm internal organs if can harm internal organs if inhaledinhaled, , ingestedingested or absorbed or absorbed
• Beta radiationBeta radiation– small, more energy, more penetrating abilitysmall, more energy, more penetrating ability– usually enter thru damaged skin, ingestion or inhalationusually enter thru damaged skin, ingestion or inhalation
• Gamma radiation & X-raysGamma radiation & X-rays– most dangerous penetrating radiationmost dangerous penetrating radiation– may produce localized skin burns and extensive internal damagemay produce localized skin burns and extensive internal damage
Radiation ExposureRadiation Exposure
Radiation exposure may result in:Radiation exposure may result in:• external injuryexternal injury• contamination contamination • incorporation injuryincorporation injury• combined injuriescombined injuries
Radiation ExposureRadiation Exposure
Effect of Injury dependent upon:Effect of Injury dependent upon:• duration of exposureduration of exposure• distance from the sourcedistance from the source• shieldingshielding
At risk for delayed complicationsAt risk for delayed complications
Radiation Exposure Radiation Exposure ManagementManagement
SAFETY!!!SAFETY!!!• Two Most Useful Tools for Radiation Two Most Useful Tools for Radiation
Incident ManagementIncident Management• Protective EquipmentProtective Equipment
Need for decontaminationNeed for decontamination Likelihood of survivalLikelihood of survival ABCs and Supportive CareABCs and Supportive Care
Pediatric BurnsPediatric Burns
Thin skinThin skin• increases severity of burning relative to adultsincreases severity of burning relative to adults
Large surface/volume ratioLarge surface/volume ratio• rapid fluid lossrapid fluid loss• increased heat loss increased heat loss hypothermia hypothermia
Delicate balance between dehydration Delicate balance between dehydration and overhydrationand overhydration
Immature immunological response Immature immunological response sepsissepsis
Always consider possibility of child abuseAlways consider possibility of child abuse
Geriatric BurnsGeriatric Burns
Decreased myocardial reserveDecreased myocardial reserve• fluid resuscitation difficultyfluid resuscitation difficulty
Peripheral vascular disease, diabetesPeripheral vascular disease, diabetes• slow healingslow healing
COPDCOPD• increases complications of airway injuryincreases complications of airway injury
Poor immunological response - SepsisPoor immunological response - Sepsis % mortality ~= age + % BSA burned% mortality ~= age + % BSA burned