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Lesson 09

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Lesson 09

  1. 1. Lesson 9 Thermal Trauma
  2. 2. Objectives <ul><li>As a result of active participation in this lesson, you should be able to: </li></ul><ul><ul><li>Differentiate between critical and noncritical thermally injured patients </li></ul></ul><ul><ul><li>Differentiate the treatment needs of thermally injured patients based on depth of injury, body surface area involved, mechanism of burn, and coexisting injuries and health conditions </li></ul></ul><ul><ul><li>Discuss the specific needs of thermally injured patients related to fluid resuscitation, pain management, and thermoregulation </li></ul></ul>
  3. 3. Thermal Trauma <ul><li>WHO statistics for 2002 estimates 322,000 deaths worldwide due to smoke, fire, and flames </li></ul><ul><li>A large percentage of burns are a result of intentional injury, particularly against children, women, and the elderly </li></ul>
  4. 4. Thermal Trauma <ul><li>Burns are not just isolated to skin; large burns are a multisystem injury capable of life-threatening affects to the heart, lungs, kidneys, GI tract, and immune system </li></ul><ul><li>Most common causes of death relative to burn injuries are complications and respiratory failure </li></ul>
  5. 5. Scenario <ul><li>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. </li></ul>
  6. 6. Scenario: Scene Size-Up <ul><li>What are the considerations for scene safety? </li></ul><ul><li>What are the potential injuries associated with this mechanism? </li></ul>
  7. 7. Scenario <ul><li>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. </li></ul>
  8. 8. Primary Survey <ul><li>Patient is awake, is in obvious pain, and has great difficulty responding verbally. </li></ul><ul><li>You note sounds of stridor on inspiration. </li></ul><ul><li>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. </li></ul>
  9. 9. Scenario: Critical Thinking <ul><li>Does your assessment of this patient indicate an inhalation injury? </li></ul><ul><li>How does this affect your treatment of this patient? </li></ul>
  10. 10. Inhalation Injury <ul><li>Thermal </li></ul><ul><ul><li>Dry air vs. steam </li></ul></ul><ul><li>Asphyxiation/smoke inhalation </li></ul><ul><ul><li>Carbon monoxide </li></ul></ul><ul><ul><li>Cyanide gas </li></ul></ul><ul><ul><li>Particulate matter </li></ul></ul><ul><li>Delayed toxin-induced lung injury </li></ul><ul><ul><li>May manifest after several days </li></ul></ul><ul><ul><li>Severity related to composition of inhaled gas and duration of exposure </li></ul></ul>
  11. 11. Signs of Inhalation Injury <ul><li>Singed or absent facial hair </li></ul><ul><li>Facial burns </li></ul><ul><li>Difficulty speaking, hoarseness, or stridor </li></ul><ul><li>Soot in oropharynx </li></ul><ul><li>Oropharyngeal edema </li></ul><ul><li>Crackles auscultated in lungs </li></ul><ul><li>Respiratory failure </li></ul>
  12. 12. Inhalation Injury: Treatment <ul><li>Early intubation before airway becomes occluded </li></ul><ul><li>High-flow oxygen </li></ul><ul><li>Rapid transport to an appropriate facility </li></ul><ul><li>Early and aggressive airway management is critical for patients with inhalation injury! </li></ul>
  13. 13. Scenario: Treatment <ul><li>Stop the burning process! </li></ul><ul><li>What are the patient’s immediate airway needs? </li></ul><ul><li>Does this patient require assisted ventilations? </li></ul>
  14. 14. Scenario: Critical Thinking <ul><li>What degree/thickness of burns are likely in this patient? </li></ul><ul><li>Which type of injury is likely causing your patient’s pain? </li></ul><ul><li>Does the degree/thickness of burns alone make this a critical patient? </li></ul><ul><ul><li>Why or why not? </li></ul></ul>
  15. 15. Fluid Resuscitation <ul><li>Most critical to preventing hypovolemic shock; second only to airway in early burn treatment </li></ul><ul><li>Preference is for lactated Ringer’s solution </li></ul><ul><li>Avoid starting IVs in burned tissue, where edema can make veins difficult to find and lines difficult to secure </li></ul><ul><li>Patients with both thermal and smoke inhalation require additional fluids over what would be given patient with thermal burns only; withholding fluids aggravates the severity of pulmonary injury </li></ul>
  16. 16. Fluid Resuscitation: Parkland Formula <ul><li>Calculates the fluid required during the initial 24 hours from point of injury </li></ul><ul><ul><li>4 mL/kg/%TBSA burn </li></ul></ul><ul><ul><li>Divide the 24-hr value by 2 to determine fluid value to be given from time of injury to hour 8 </li></ul></ul><ul><ul><li>Divide total by 8 for hourly rate </li></ul></ul>
  17. 17. Critical Thinking <ul><li>Is this patient’s circulation compromised? </li></ul><ul><li>Calculate appropriate fluid resuscitation for a patient weighing 80 kg and with 36% body surface area burns using the Parkland formula. </li></ul><ul><li>How would you administer these fluids? </li></ul>
  18. 18. Anatomy of the Skin <ul><li>Epidermis (outermost layer) </li></ul><ul><li>Dermis (nerve endings, blood vessels) </li></ul><ul><li>Subcutaneous (fat and muscle) </li></ul>
  19. 19. Determining the Severity of Burns <ul><li>First-Degree or Superficial Burns </li></ul><ul><li>Involves the epidermis </li></ul><ul><li>Red and painful </li></ul><ul><li>Second-Degree or Partial-Thickness Burns </li></ul><ul><li>Involves the epidermis and potentially some portion of the dermis </li></ul><ul><li>Blisters and/or glistening or wet base </li></ul><ul><li>Third-Degree or Full-Thickness Burns </li></ul><ul><li>Thick, dry, white leathery </li></ul><ul><li>Visible thrombosis of blood vessels </li></ul><ul><li>Fourth-Degree Burns </li></ul><ul><li>Involves all layers of skin, fat, bone, and underlying organs </li></ul>
  20. 20. Scenario: Critical Thinking <ul><li>What degree/thickness of burns does your observation of this patient indicate? </li></ul><ul><li>Which of these values is likely causing your patient’s pain? </li></ul><ul><li>Do these values alone indicate a critical patient? Why or why not? </li></ul>
  21. 21. Rule of Nines
  22. 22. Scenario: Critical Thinking <ul><li>What percent of body surface area (BSA) burns does your observation of this patient indicate? </li></ul><ul><li>Does this value alone indicate a critical patient? Why or why not? </li></ul><ul><li>How does this value affect your treatment? </li></ul>
  23. 23. Complicating Factors <ul><li>Age/gender </li></ul><ul><li>Chronic disease </li></ul><ul><li>Circumferential burns </li></ul><ul><li>Distracting injury </li></ul><ul><li>Fluid loss </li></ul><ul><li>[Already compromised] Immune system </li></ul>
  24. 24. Scenario: How would you treat this patient? <ul><li>Stop the burning process! </li></ul><ul><li>What are the patient’s airway needs? </li></ul><ul><li>Does this patient require assisted ventilations? </li></ul>
  25. 25. Scenario: How would you treat this patient? <ul><li>What can be done to improve the patient’s circulation? </li></ul>
  26. 26. Wound Dressing <ul><li>Dry sterile dressings </li></ul><ul><li>Wet dressings only when BSA is less than 10% </li></ul><ul><li>Keep burn areas covered to reduce pain </li></ul><ul><li>Do not remove clothing that has adhered to skin </li></ul><ul><li>Do not break blisters prehospital </li></ul><ul><li>Do not apply ointments, salves, or gels </li></ul>
  27. 27. Scenario: How would you treat this patient? <ul><li>What kinds of wound dressings would you apply to this patient? </li></ul><ul><li>Is the loss of body heat a consideration with this patient? </li></ul>
  28. 28. Scenario: How would you treat this patient? <ul><li>Does this patient require pain management? </li></ul>
  29. 29. Pain Management <ul><li>Ensure afflicted areas are covered </li></ul><ul><ul><li>Airflow across burn area causes pain </li></ul></ul><ul><li>Follow local protocols for pharmacological interventions </li></ul>
  30. 30. Scenario: How would you treat this patient? <ul><li>What transport decisions are involved with this patient? </li></ul>
  31. 31. Chemical Burns <ul><li>Can be classified as: </li></ul><ul><ul><li>Acid — pH of 7 (neutral) to 0 (strong acid) </li></ul></ul><ul><ul><li>Base — pH of 7 to 14 </li></ul></ul><ul><ul><li>Organic (i.e., gasoline) </li></ul></ul><ul><ul><li>Inorganic (i.e., hydrofluoric acid) </li></ul></ul>
  32. 32. Chemical Burns <ul><li>Ensure scene safety for you, your partner, and your patient </li></ul><ul><li>Wear protective gear </li></ul><ul><li>In most cases, flushing the affected area with copious amounts of water will dilute and remove the chemical </li></ul><ul><ul><li>Powdered chemicals should be brushed off first </li></ul></ul>
  33. 33. Chemical Burns <ul><li>If protocol is unknown, contact the nearest poison control center </li></ul><ul><li>Material Safety Data Sheets (MSDS) should be transported along with patient </li></ul><ul><li>Chemical burns of the eyes should be flushed with water continuously </li></ul><ul><ul><li>Morgan lens is a useful adjunct </li></ul></ul><ul><li>Treat all chemical burn patients as critical </li></ul>
  34. 34. Electrical Burns <ul><li>Can be classified as: </li></ul><ul><li>Current burns </li></ul><ul><li>Arc (flash) </li></ul><ul><li>Contact burns </li></ul>
  35. 35. Electrical Burns <ul><li>Injury can include: </li></ul><ul><ul><li>Thermal burns </li></ul></ul><ul><ul><li>Altered mentation </li></ul></ul><ul><ul><li>Intracranial bleeding </li></ul></ul><ul><ul><li>Partial or full paralysis </li></ul></ul><ul><ul><li>Cardiac arrhythmias </li></ul></ul><ul><ul><li>Kidney failure </li></ul></ul><ul><ul><li>Associative injuries </li></ul></ul><ul><ul><ul><li>Ruptured tympanic membranes </li></ul></ul></ul><ul><ul><ul><li>Spinal and long bone fractures </li></ul></ul></ul>
  36. 36. Electrical Burns <ul><li>Ensure scene safety for you, your partner, and your patient </li></ul><ul><li>Immobilize spine if fractures are detected or suspected </li></ul><ul><li>Administer IV lactated Ringer’s or normal saline to flush myoglobin and prevent kidney damage </li></ul>
  37. 37. Patients Requiring Burn Centers <ul><li>Inhalation injury </li></ul><ul><li>Second/third-degree burns in children under 10 years of age or adults older than 50 years of age </li></ul><ul><li>Second/third-degree burns of more than 20% TBSA </li></ul><ul><li>Second/third-degree burns involving face, hands, feet, genitalia, perineum, and major joints </li></ul>
  38. 38. Patients Requiring Burn Centers <ul><li>Second/third-degree burns with complicating trauma where burn poses greatest risk </li></ul><ul><li>Chemical burns </li></ul><ul><li>Electrical burns </li></ul><ul><li>Patients with preexisting medical disorders </li></ul>
  39. 39. Summary <ul><li>Thermal trauma is a significant cause of morbidity and mortality </li></ul><ul><li>Immediate concerns are for airway, breathing, and circulation </li></ul><ul><li>Large burns are a multisystem problem </li></ul><ul><li>EMS providers play a critical role in recognizing burn center criteria and in the initial management of burn patients </li></ul>
  40. 40. <ul><li>QUESTIONS? </li></ul>

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