2. Topics
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
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4. Introduction to Burn Injuries
1.25–2 million Americans treated for burns
annually
– 45,000 require hospitalization
– 90% of burns can be prevented
– 3–5% considered life threatening
– 2nd leading cause of death for children <12
– Half of all tap-water burns occur to children <5
5. Introduction to Burn Injuries
Greatest Risk
– Very young and very old
– Infirm
– Firefighters
– Metal smelters
– Chemical workers
Drugs and alcohol play major role
7. Introduction to Burn Injuries
Reducing burn injuries
– Improved building codes
– Safer construction techniques
– Sprinkler systems
– Use of smoke detectors
– Educational campaigns aimed primarily at school
children
9. Anatomy and Physiology
of the Skin
Layers
– Epidermis
– Dermis
– Subcutaneous
– Underlying
structures
Fascia
Nerves
Tendons
Ligaments
Muscles
Organs
10. Anatomy and Physiology
of the Skin
Functions of the Skin
– Protection from infection
– Sensory organ
Temperature
Touch
Pain
– Controls loss and movement of fluids
– Temperature regulation
– Insulation from trauma
– Flexible to accommodate free body movement
13. Thermal Burns
Molecular structure changed by heat
Extent of burn damage depends on:
– Temperature of agent
– Concentration of heat
– Duration of contact
14. Thermal Burns
Jackson’s Theory of Thermal Wounds
– Zone of Coagulation
Area in a burn nearest the heat source
Suffers the most damage as evidenced by clotted blood and
thrombosed blood vessels
– Zone of Stasis
Characterized by decreased blood flow
– Zone of Hyperemia
Increased blood flow
18. Thermal Burns
Hypermetabolic Phase (Stage 3)
– Large increase in the body’s need for nutrients as
it repairs itself
– Fluid and electrolytes begin to move back into the
vasculature
– Influx of fluid within vascular space causes the
GFR to increase, leading to diuresis
– Fluid shifts may lead to hypernatremia and
hypokalemia
– Cardiac workload and O2 consumption increase
20. Electrical Burns
Terminology
– Voltage – the pressure
Difference of electrical potential between two points
Different concentrations of electrons
– Amperes – the velocity
Strength of electrical current
– Resistance (Ohms) – the friction
Opposition to electrical flow
21. 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
– Increased damage inside body
Smaller the point of contact, the more
concentrated the energy, the greater the
injury
26. Radiation Injury
Radiation
– Transmission of energy
Nuclear energy
Ultraviolet light
Visible light
Heat
Sound
X-rays
Radioactive Substance
– Emits ionizing radiation
– Radionuclide or radioisotope
27. Types of Radiation
Alpha
– Very weak energy source
– Only significant if ingested
Beta
– Can travel 6 to 10 feet
– May penetrate clothing
Gamma
– Most powerful type of ionizing
radiation
– Penetrates entire body
Neutron
– Great penetrating power
28. Radiation Injury
Exposure can occur through two
mechanisms:
– Direct exposure to a strong radioactive source
– Contamination by dust, debris, or fluids that
contain very small particles of radioactive material
29. Radiation Injury
Three factors are important to remember:
– Duration
The longer exposed, the more absorption
– Distance
Travel farther from the source for safety
– Shielding
The more material between you and the source, the less
radioactive exposure you experience
31. Radiation Injury
Different tissues are sensitive to different
levels of absorbed radiation
Signs and symptoms of exposure
– Nausea and fatigue
– Anorexia, vomiting, diarrhea, and malaise
– Erythema of the skin
– Confusion
– Watery diarrhea
– Physical collapse
Long-term effects include cancer and sterility
32. Inhalation Injury
Toxic Inhalation
– Synthetic resin
combustion
– More common than
thermal injury
Carbon Monoxide
Poisoning
– Colorless, odorless,
tasteless gas
– Byproduct of
incomplete combustion
of carbon products
Suspect with faulty
heating unit
33. 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
– Symptoms:
Stridor or “crowing” inspiratory sounds
Singed facial and nasal hair
Black sputum or facial burns
Progressive respiratory obstruction and arrest due to
swelling
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39. Depth of Burn
Depth of burn damage is normally
classified into three categories
43. Body Surface Area
Rule of Nines
– Best used for large surface areas
– Expedient tool to measure extent of burn
Rule of Palms
– Irregular or splash burns
– Best used for burns <10% BSA
47. Systemic Complications
Hypothermia
– Disruption of skin and its ability to thermoregulate
Hypovolemia
– Shift in proteins, fluids, and electrolytes to the
burned tissue
Eschar
– Hard, leathery product of a deep full-thickness
burn
– Dead and denatured skin
48. Systemic Complications
Infection
– Greatest risk of burn is infection
– Carefully employ Standard Precautions
Organ Failure
– Release of myoglobin
Clogs the tubules of the kidneys
Special Factors
– Age and health
51. Assessment of Thermal Burns
Skin evaluation tells more about the body’s
condition than any other aspect of patient
assessment.
– Must be deliberate, careful, and complete
Assign burns the appropriate priority for care.
53. Assessment of Thermal Burns
Initial Assessment
– Form a general impression of the patient
– Ensure the airway is patent
Look for the signs of any thermal or inhalation injury
Provide high-flow, high-concentration oxygen
– Ensure that the patient’s breathing is adequate
54. 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 affected
Age of patient affected
55. Severity of Thermal Burns
Any partial- or full-thickness burn involving hands, feet, joints, face, or genitalia
>30% BSA
Partial Thickness
Inhalation Injury
>10% BSA
Full Thickness
Critical
>2% BSA
Full Thickness
>50% BSA
Superficial
<2% BSA
Full Thickness
<15% BSA
Partial Thickness
<50% BSA
Superficial
>15% BSA
Partial Thickness
Moderate
Minor
Burn Severity
56. Assessment of Thermal Burns
Ongoing Assessment
– Non-critical: Reassess Q 15 min
– Critical: Reassess Q 5 min
– Watch for early signs of hypovolemia and airway
problems
Be cautious of aggressive fluid therapy
– Carefully monitor distal circulation and sensation
with any circumferential burn
58. Management of Thermal Burns
Includes the prevention of shock,
hypothermia, and any further wound
contamination
Care is divided into two categories:
– Local and minor burn care
– Moderate and severe burn care
59. Management of Thermal Burns
Local and Minor Burns
– Local cooling
Partial thickness: <15% of BSA
Full thickness: <2% BSA
– Remove clothing
– Cool or cold water immersion
– Consider analgesics
Morphine sulfate
Fentanyl (Sublimaze)
60. Management of Thermal Burns
Moderate to Severe Burns
– Dry sterile dressings
– Maintain warmth
Prevent hypothermia
– Consider aggressive fluid therapy
– Burns over IV sites:
Place IV in partial-thickness burn site
– Consider analgesics
Morphine sulfate
Fentanyl (Sublimaze)
61. Management of Thermal Burns
Fluid resuscitation
– Parkland Formula
4 mL X weight X % burn
½ volume in first 8 hours
Second ½ over last 16 hours
– Where transport time is short (less than 1 hour)
0.25 mL X Patient weight in kg X BSA burned = Amount
of fluid
62. Management of Thermal Burns
Moderate to Severe Burns
– Caution for fluid overload
Frequent auscultation of breath sounds
– Consider analgesic for pain
Morphine
Fentanyl
– Prevent infection
63. Management of Thermal Burns
Inhalation Injury
– Provide high-flow O2
by NRB
Consider intubation if
swelling
Consider hyperbaric
oxygen therapy
66. Assessment and Management
of Electrical, Chemical, and
Radiation Burns
Electrical Injuries
– Safety
Turn off power
Energized lines act as whips
Establish a safety zone
– Lightning strikes
High voltage, high current, high energy
Lasts fraction of a second
No danger of electrical shock to EMS
67. Electrical Injuries
Entrance and exit wounds
Remove clothing, jewelry, and leather items
Treat any visible injuries
ECG monitoring
Consider fluid bolus for serious burns.
– 20 ml/kg
Consider sodium bicarbonate
– 1 mEq/kg
Consider mannitol:
– 10 g
68. Chemical Burns
Chemical Burns
– Scene size-up
Hazardous materials team
Establish hot, warm, and cold zones
Prevent personnel exposure from chemical
– Specific Chemicals
Phenol
Dry lime
Sodium
Riot control agents
69. Chemical Burns
Specific Chemicals
– Phenol
Industrial cleaner
Alcohol dissolves phenol
Irrigate with copious amounts of water
– Dry Lime
Strong corrosive that reacts with water
Brush off dry substance
Irrigate with copious amounts of cool water
Prevents reaction with patient tissues
70. Chemical Burns
Sodium
– Unstable metal
– Reacts vigorously with water
– Decontaminate:
Brush off dry chemical
– Cover the wound with oil substance used to
store metal
71. Chemical 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 and symptoms
Coughing, gagging, and vomiting
Eye pain, tearing, temporary blindness
– Management
Irrigate eyes with normal saline
77. Radiation Burns
Radiation Burns
– Notify hazardous materials team
– Establish safety zones
Hot, warm, and cold
– Personnel positioned upwind and uphill
– Use older rescuers for recovery
– Decontaminate ALL rescuers, equipment, and
patients
78. Assessment and Management
of Electrical, Chemical, and
Radiation Burns
Ongoing Assessment
– Re-evaluate initial assessment
– Re-evaluate all interventions
79. Summary
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
