Download - 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
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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Circumferential Burns
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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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.
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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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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 bodybecause liquid cools while flowing down - occur
usually on front of body
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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 toiletingmishaps
may be seen on buttocks on extremities - stocking or glove appearance
where feet, hand dipped into hot water
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Abuse/Intentional Burns
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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Questions?