Point of Wounding: Burn Complications

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  • 1. Burn Complications
    • Department of Combat Medic Training
    • C168W005
  • 2. Terminal Learning Objective
    • Given a burn casualty ,
    • treat the burn
    • IAW Prehospital Trauma Life Support Chapters 13 and 21 and the principles of Tactical Combat Casualty Care.
  • 3. Enabling Learning Objective
    • Given a combat casualty suffering from burns,
    • assess a burn casualty
    • IAW Prehospital Trauma Life Support and the principles of Tactical Combat Casualty Care Chapter 13.
  • 4. Casualty Assessment
    • Care Under Fire
    • The priorities of Care Under Fire remain the same for burn casualties as with any other combat casualty.
  • 5. Casualty Assessment
    • Burn casualties are trauma casualties and may have sustained injuries other than the thermal trauma.
    • Follow your assessment protocols.
    • Tactical Field Care
    • What is the first step?
    • Stop the burning process
  • 6. Casualty Assessment
    • Hot gases and flames cause what airway problems?
    • Edema of the airway above the vocal cords and can occlude the airway.
    What early signs may be present? Facial burns, singed eyebrows, carbonaceous sputum are all signs of an inhalation burn
  • 7.  
  • 8.  
  • 9. Casualty Assessment
    • How will circumferential burns of the chest affect a casualty?
    • By constricting the chest wall. The casualty may suffocate due to an inability to inhale deeply.
    • In what category are combat casualties with circumferential burns evacuated?
    • Urgent
  • 10. Casualty Assessment
    • Circulation
    • Ensure all other hemorrhage is controlled.
    • Assess for circumferential burns.
    • Obtain vascular access.
    • Casualties suffering from burns covering greater than 20% of the total body surface area
    • Immediately begin fluid resuscitation following
    • "The Rule of Tens"
  • 11. Casualty Assessment
    • Avoid placement through burned tissue unless no other site is available.
    • An IO catheter should be placed if IV access cannot be established.
  • 12. Casualty Assessment
    • Expose the casualty completely and inspect for any other possible life threatening injuries.
    • Replace the casualty’s body armor and helmet if there is still significant risk of enemy contact during tactical field care or TACEVAC care.
  • 13. Casualty Assessment
    • Remove
    • nonadherent clothing, jewelry and watches,
    • if not done earlier.
  • 14. Casualty Assessment
    • Burn casualties are not able to control their own body temperature effectively.
    • Hypothermia is possible even in warm weather.
    • What methods are available to control body temperature in a combat environment?
    Answers will vary, but may include: Blankets, casualty blankets, clothing
  • 15. Casualty Assessment
    • Burnt tissue swells.
    • How does this swelling affect extremities?
    • Swelling and edema, especially with circumferential burns of the extremities,
    • can compromise distal circulation.
  • 16. Special Considerations
    • Age
    Respiratory Injury The leading cause of death in fires is not thermal injuries but the inhalation of toxic smoke. The three elements of smoke inhalation are thermal injury, asphyxiation and toxin-induced lung injury (delayed).
  • 17. What degree burn? Second Degree Third Degree Burns Fourth Degree First Degree
  • 18. Burn Size How are scattered burns estimated? Using the surface of the casualty’s palm to represent 1% BSA, the total burn percentage is estimated.
  • 19. Transport
    • Which burn casualties get transported as Urgent Surgical?
    • Inhalation injuries.
    • 2 nd Degree burns >20%TBSA and 3 rd or 4 th degree.
    • Burns to the face, hands, feet, genitalia, perineum or major joints.
    • Electrical and Chemical Burns.
    • Burn casualty with preexisting illnesses.
    • Casualties with burns and trauma.
    • Children
  • 20. Prevention
    • Remember the Army Combat Shirt (ACS) from your Introduction to Battlefield Medicine Class?
    Designed to provide FR protection to those areas of the body not protected by body armor Arms exposed beyond the protection of body armor resulting in full thickness burns Hands and wrists protected by FR gloves Neck and chest well protected by wearing Improved Body Armor
  • 21. Check on your Learning…
    • How do circumferential burns complicate casualty care?
    • Increased chance of compromise to distal circulation due to swelling and edema.
    • Constrict the chest wall to such a degree that the casualty suffocates from inability to take a deep breath.
  • 22. Enabling Learning Objective
    • Given a combat casualty suffering from burns,
    • treat a burn casualty
    • IAW Prehospital Trauma Life Support Chapters 13 and 21 and the principles of Tactical Combat Casualty Care.
  • 23. Burn Wound Care
    • What is the goal of burn wound care?
    • Prevent shock, infection and minimize disfiguration.
    • What type of dressing is used to cover burns?
    • Dry sterile dressings
    • Dry sterile sheets or towels
    • Additionally, prevent hypothermia!
  • 24. Burn Wound Care
    • This procedure would be performed by a medical officer at a Battalion Aid Station or FMSC,
    • NOT by a 68W.
  • 25. Management
    • Burn casualties have special fluid resuscitation needs.
    • Your MO or standing orders may direct morphine for pain management.
    • If the casualty suffers from only burns,
    • DO NOT provide antibiotics.
    • For casualties with burns & penetrating trauma,
    • antibiotics are indicated.
  • 26. DO NOT Apply ointments until the casualty has been evaluated. Open Blisters Open eyelids if casualty suffers from thermal burns
  • 27. Chemical burns
    • Severe chemical burns to rescuers have occurred because of the inability of the rescuer to identify a chemical source.
    Alkali Burn to the Eye Remove clothing. Brush away dry chemicals. Remove liquid chemicals by flushing with water. Irrigate eyes.
  • 28. White Phosphorus
    • What is special about white phosphorus?
    • A chemical substance that burns when exposed to oxygen without having to be ignited.
    • Cover with anything that seals the WP from the air. Maintain the seal until it can be removed.
  • 29. Inhalation Burns
    • Altered mental status is a sign the brain is not receiving enough oxygen.
    If difficulty breathing increases, be prepared to perform a surgical cricothyroidotomy
  • 30. Electrical Burns
    • Be careful.
    • Turn off the source of electricity before any rescue attempt is made if possible.
    • May cause an abnormal heartbeat and loss of pulse.
    • Consider AED use. Casualties with normal healthy hearts have a great chance for survival.
  • 31. Electrical Burns
    • Electrical injuries and crush injuries have many similarities.
    • Ruptured tympanic membranes and
    • fractures to multiple areas of the spine and long bones are also possible with electrical burn injuries.
  • 32. Radiation Burns
    • Treatment interventions for radiation casualties are the same as other types of burns.
    • The most devastating effects of radiation poisoning in those casualties that survive the initial exposure, will not appear until a few hours after the exposure.
  • 33. Fluid Resuscitation for a Burn Casualty
    • Fluid is needed to prevent a burn casualty from going into hypovolemic shock.
    • How do you think burn casualties lose fluid?
    • Initiate fluid resuscitation as soon as access is established.
    For casualties suffering from only burns, Lactated Ringer’s is the solution of choice. If the casualty is in shock due to other injuries, follow combat casualty fluid resuscitation protocols. (Hextend Bolus x2)
  • 34. Rule of Tens
    • Estimate the total body surface area (TBSA) burned to the nearest 10%.
    • Percentage TBSA (to the nearest 10%)
    • X
    • 10 ml per hour for adults weighing 88-176 pounds (40-80 kgs).
    • Example:
    • 30% TBSA of a 170 pound person was burned
    • 30 X 10 = 300 ml/hour
  • 35. Rule of Tens
    • Calculate the following fluid needs:
    • A 165 lbs Soldier has burned 27% TBSA
    • 30% (round up) X 10 =
    • 300 ml / hour
  • 36. Rule of Tens
    • For every 25 pounds above 175 pounds, increase the initial rate by 100 ml/hour.
    • A 200 pound Soldier suffers from burns to approximately 50% TBSA.
    • 50 X 10 =
    • 500 ml/hour
    • + 100 ml/hr =
    • 600 ml/hour
  • 37. Rule of Tens
    • Titrate fluids until the urine output is 30-50 ml/hr
    • (This may require the administration of a urinary catheter- a skill level 2 task)
    • Overhydration of IV fluids has been a problem with burn casualties.
    • Massive amounts of IV fluids are no longer the standard of care.
  • 38. Check on your Learning…
    • Based on what you have learned:
    • If the tactical situation permits, for which burn casualty would CPR be a reasonable intervention?
    • Electrical Burn (Electrocution Casualty)
    • What type of dressing is used on burns?
    • Dry, sterile dressing.
  • 39. Check on your Learning…
    • Based on your previous training, what would be some signs or symptoms that a casualty is suffering from inhalation burns?
    •  
    • Difficulty breathing (dyspnea)
    • Coughing, stridor
    • Breath has "smoky" or "chemical" smell
    • Black residue in patient's nose and mouth
    • Nasal or facial hairs are singed
    • Burns to the head, the face, or the front of the trunk
  • 40. Check on your Learning…
    • If the casualty becomes altered and shows signs of increased difficulty breathing what do you do?
    • Prepare for and provide with a surgical cric.
    •  
    • What is the initial treatment for white phosphorus burns?
    • Cover the area with water, saline, a wet cloth, or wet mud; keep the area covered with the wet material to exclude air and to prevent any retained particles from re-igniting and further burning.
  • 41. Summary
    • You are called to a small vehicle fire. Your casualty (an 80 kg. male) has second-degree thermal burns of his anterior trunk, anterior arms, anterior legs & groin.  Using the Rule of Nines, calculate TBSA burned.
    • Anterior trunk=18% Anterior arms=9% Anterior legs=18% Groin=1%
    • TBSA burned=46%
    •  
    • Calculate the casualty’s fluid resuscitation needs using the Rule of Tens .
    • 50 X 10 = 500 ml/hour
  • 42. Summary
    • SFC Romero (225 pounds) went to the beach and fell asleep on the sand. When he awoke, his posterior trunk, posterior arms and posterior legs are red and blistered. He is brought to the BAS for care.
    • What type of burn does this Soldier have?
    • 2nd degree
    •  
    • Calculate the percentage of BSA burned.
    • Posterior trunk= 18% Posterior arms=9% Posterior legs=18%
    • TBSA burned=45%
    •  
    • Calculate Rule of Tens fluid resuscitation needs.
    • 50 X 10 = 500 ml/hour
    • + 200 ml/hr = 700 ml/hour
  • 43. Questions??