Instructor Notes: WHO publishes a fact sheet “Facts about injuries: burns (2004)” available from their website for download in .pdf (291kb). Go to http://www.who.int/violence_injury_prevention/publications/factsheets/en/ The statistics provided do not include deaths resulting from other types of burns such as chemical or electrical burns. It is important to research statistical facts relevant to the participants, system, and environment you are teaching in (i.e., in the U.S.A., each year approx. 61,000 hospitalizations are due to burn injury). The Internet is a great tool for doing research. The WHO site is a good one to search, as is the National Center for Injury Prevention and Control for the U.S.A. (http://www.cdc.gov/ncipc/wisqars/) Key Points: Intentional injury is a serious concern, and all circumstances relative to such potential should be taken into account. Consider your local protocols for reporting such abuses. The potential for distraction by burn injury may interfere with patient care, such as maintaining good airway and treating for shock.
Instructor Notes: Key Points: Physiologic response to thermal injury is both local and systemic. Direct tissue injury causes increased capillary permeability, edema, and evaporative fluid loss. Systemic response is also due to increased capillary permeability: flux of fluid and electrolytes in circulation results in generalized edema, circulatory hypovolemia, and hyperviscosity (burn shock). Impaired cardiac function, increased pulmonary vascular resistance, decreased myocardial contractility Kidney, GI organs, and peripheral tissues are hypoperfused Tissue ischemia Acidosis Inhalation injury may be exacerbated by pulmonary edema
Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. For example, if participants respond with a list of potential injuries, follow up with questions such as “What makes you say that?” This verifies understanding of the mechanism of injury. Key Points: Primary scene safety consideration is the accelerant and any remaining fire. Remember to take BSI precautions. The mechanism is suspicious for burns, smoke and/or heated gas inhalation, secondary injuries, or tertiary traumatic injury.
Key Points: Consider that burns to the neck/torso and upper extremities may make the carotid and radial sites unavailable for assessment of pulse rate. What other sites might you consider if this were the case?
Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: Inhalation injury of the upper airway is indicated by facial burns, difficulty speaking, stridor. A patent airway is critical. Transport without delay.
Key Points: Most thermal inhalation injury presents in the upper airway (supraglottic) structures. Dry air is a poor conductor of heat. Large surface areas of nasopharynx cool the heated air before it reaches the vocal cords. Vocal cords adduct (close) by reflex, further protecting lower structures. Steam has 4,000 times the heat-carrying capacity as dry air and can cause significant damage to lower (infraglottic) airway structures. Steam injuries are rare. Carbon monoxide (CO) causes death by cellular hypoxia or asphyxia. Inadequate delivery of oxygen to the tissues CO binds to hemoglobin with a greater affinity than oxygen Treatment: remove from source and administer high-flow oxygen Cyanide gas is produced by burning plastics. Disrupts body’s ability to use oxygen to produce energy Treatment: rapid transport to ED with access to antidote therapy
Key Points: What is an appropriate facility in your location, considering transport times and levels of care available? Specialized burn care Access to immediate surgical interventions Unique modes of mechanical ventilation Hyperbaric oxygenation for CO poisoning
Key Points: Stop the burning with tepid water Manage the airway BLS: high-flow oxygen, rapid transport, assist ventilations as appropriate, call ALS back-up if available ALS: consider intubation and assisted ventilation; use pharmacological intervention with extreme caution
Key Points: Potential for massive fluid shifts due to edema Evaporative losses at burn site Fluid resuscitation aimed at not only replacing immediate fluid deficits but also anticipating loss of further fluids over the next 24 hours
Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: Accurate blood pressure also may be difficult to ascertain: Burns to extremities may not allow placement of a BP cuff. Circumferential burns, full-thickness burns, and edema to the extremities may reduce distal limb perfusion. Regardless of actual BP value, this patient’s circulation will be compromised by his body’s response to the burn. Parkland formula (4 mL × BSA × weight in kg) 24-hour value = 11520 mL Half to be delivered within first 8 hours after injury (11520 mL/2 = 5760 mL) Hourly rate is 5760 mL/8 hrs = 720 mL/hour
Key Points: Skin is the largest organ in the body. Skin serves many functions: Protection from external environment Regulation of fluids Thermoregulation Sensation Metabolic adaptation
Key Points: Burn severity may be difficult to accurately assess in the field. Burn trauma is a dynamic process in that a burn may transition from one level of severity to another.
Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: Although it is difficult to assess burn depth accurately in the field, visual indications are that this patient has sustained first- and second-degree burns. Pain is usually present for all burns except fourth degree. Even though there is extensive tissue damage in third-degree burns, there are usually areas of second-degree tissue burns surrounding the third-degree burns, which account for the pain. These values alone usually require surface area information and estimate of area affected to be meaningful. For example, a first-degree burn can be critical if it covers 90% of a patient’s body; a second-degree burn may be considered manageable if it only covers a 1% portion of a patients arm, whereas 1% of genitalia is critical.
Key Points: Note the difference in values for child vs. adult in these areas: Head, 18 vs. 7 Leg, 13.5 vs. 18
Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: 18% value for anterior chest; 4.5% value for each anterior upper extremity; 4.5% value for head. Total = 31.5% As was the case with burn depth, this information alone is less valuable without burn depth and areas affected. Primary survey information along with BSA value, burn depth, and burn areas affected suggest that this patient must be treated and transported immediately.
Instructor Notes: Ask your students to discuss the relevance and affect of each of these complicating factors. Key Points: Age/gender — skin is thinner in children, women, and the elderly. Chronic disease — additional complications, longer healing process. Circumferential burns — create a tourniquet effect that can restrict blood flow to an extremity or inhibit respiration when the chest is involved. Distracting injury — secondary trauma. Fluid loss — hypovolemic shock. Compromised immune system — difficulty combating infection.
Key Points: Stop the burning with tepid water. Manage the airway. If BLS, use high-flow oxygen and rapid transport; assist ventilations when appropriate. Call for ALS backup, if available. If ALS, consider intubation and assisted ventilation; pharmacological intervention with extreme caution.
Key Points: Fluid resuscitation is extremely important with burn patients; it can forestall hypovolemic shock. Elevate burned extremities to reduce edema and improve circulation.
Key Points: Dry dressings only Cover patient with several blankets and increase heat in unit
Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: BLS pain management includes covering all burns with dressings. ALS pain management may include narcotics or nitrous oxide; follow local protocol.
Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: This patient is considered critical and should be transported without delay to nearest burn centre. If unavailable, consider the nearest trauma center.
Instructor Notes: Consider researching what types of chemicals local industries are using and encourage participants to make themselves familiar with these.
Key Points: Most chemicals can be removed with water, but there are exceptions; some are: Dry lime and soda ash Lithium and sodium metal Hydrogen fluoride and hydrofluoric acids Become familiar with the domestic and industrial chemicals used in your area.
Instructor Notes: Obtain the Poison Control Center contact information for your area or country. U.S.A. providers also can access CHEMTREC at 1.800.424.9300 for chemical information. Key Points: Material Safety Data Sheets (MSDS) should be transported along with the patient for hospital use, if available.
Key Points: Current burns occur when an electrical current passes through tissue. Typically, entrance and exit wounds are present. Arc (flash) burns occur when tissue comes in contact with the superheated air associated with an arcing of electricity between two contact points. Contact burns occur when electrically heated metal comes in contact with tissue.
Key Points: Spinal immobilization Intense and sustained muscle contractions can fracture spines and long bones. Lightening strikes often ‘throw’ the victim, causing secondary traumatic injury.
You are dispatched to a suburban home on a cool, sunny fall day in response to a potential burn patient. The fire department also has responded. On your arrival you are informed by a member of the fire department that the 35-year-old male patient used an accelerant in a metal trash receptacle with intent to burn garbage and yard debris.
The scene has been secured by the fire department. The patient is standing upright with both arms extended and appears to be in considerable pain and distress. Most of the patient's upper torso is bare with the exception of small patches of burnt clothing that remain. Most of the patient’s hair has been burned off, and you can see varying skin discolorations from your vantage point.
Patient is awake, is in obvious pain, and has great difficulty responding verbally.
You note sounds of stridor on inspiration.
You determine the presence of reddened skin and blistering to the anterior chest and upper extremities, and what appears to be ‘raw’ flesh in the neck and facial area. All facial hair and most scalp hair has been burned off.