Burns

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CMSgt John Jonckers Superintendent 141st MDG Medical SMEE - Thailand

Burns

  1. 1. BURNS CMSgt John Jonckers Superintendent 141 st MDG Medical SMEE - Thailand
  2. 2. Anatomy of Skin <ul><li>Largest body organ </li></ul><ul><li>More than just a passive covering </li></ul>
  3. 3. Skin Functions <ul><li>Sensation </li></ul><ul><li>Protection </li></ul><ul><li>Temperature regulation </li></ul><ul><li>Fluid retention </li></ul>
  4. 4. Anatomy <ul><li>Two layers </li></ul><ul><ul><li>Epidermis </li></ul></ul><ul><ul><li>Dermis </li></ul></ul>
  5. 5. Epidermis <ul><li>Outer layer </li></ul><ul><li>Top (stratum corneum) consists of dead, hardened cells </li></ul><ul><li>Lower epidermal layers form stratum corneum and contain protective pigments </li></ul>
  6. 6. Dermis <ul><li>Elastic connective tissue </li></ul><ul><li>Contains specialized structures </li></ul><ul><ul><li>Nerve endings </li></ul></ul><ul><ul><li>Blood vessels </li></ul></ul><ul><ul><li>Sweat glands </li></ul></ul><ul><ul><li>Sebaceous (oil) glands </li></ul></ul><ul><ul><li>Hair follicles </li></ul></ul>
  7. 7. Burn Epidemiology <ul><li>2,500,000/year </li></ul><ul><li>100,000 hospitalized </li></ul><ul><li>12,000 deaths </li></ul>Third leading cause of trauma deaths in the US.
  8. 8. Pathophysiology <ul><li>Loss of fluids </li></ul><ul><li>Inability to maintain body temperature </li></ul><ul><li>Infection </li></ul>
  9. 9. Critical Factors <ul><li>Depth </li></ul><ul><li>Extent </li></ul>
  10. 10. Burn Depth <ul><li>First Degree (Superficial) </li></ul><ul><ul><li>Involves only epidermis </li></ul></ul><ul><ul><li>Red </li></ul></ul><ul><ul><li>Painful </li></ul></ul><ul><ul><li>Tender </li></ul></ul><ul><ul><li>Blanches under pressure </li></ul></ul><ul><ul><li>Possible swelling, no blisters </li></ul></ul><ul><ul><li>Heal in ~7 days </li></ul></ul>
  11. 11. Burn Depth <ul><li>Second Degree (Partial Thickness) </li></ul><ul><ul><li>Extends through epidermis into dermis </li></ul></ul><ul><ul><li>Salmon (dark) pink </li></ul></ul><ul><ul><li>Moist, shiny </li></ul></ul><ul><ul><li>Very Painful </li></ul></ul><ul><ul><li>Blisters usually present </li></ul></ul><ul><ul><li>Heal in ~7 to 21 days </li></ul></ul>
  12. 12. Burn Depth <ul><li>Third Degree (Full Thickness) </li></ul><ul><ul><li>Through epidermis, dermis into underlying structures </li></ul></ul><ul><ul><li>Thick, dry, leather feeling </li></ul></ul><ul><ul><li>Pearly gray or charred black </li></ul></ul><ul><ul><li>May bleed / ooze from vessel damage </li></ul></ul><ul><ul><li>Painless </li></ul></ul><ul><ul><li>Require grafting </li></ul></ul>
  13. 13. Burn Depth <ul><li>Often cannot be accurately determined in acute stage </li></ul><ul><li>Infection may convert to higher degree due to tissue damage </li></ul><ul><li>When in doubt, over-estimate </li></ul>
  14. 14. Burn Extent Rule of Nines
  15. 15. Burn Extent <ul><li>Adult Rule of Nines </li></ul>9 9 9 18 18 1 18, Front 18, Back
  16. 16. Burn Extent <ul><li>Pediatric Rule of Nines </li></ul><ul><ul><li>For each year over 1 year of age, subtract 1% from head, </li></ul></ul><ul><ul><li>add equally to legs. </li></ul></ul>18 9 9 13.5 13.5 1 18, Front 18, Back
  17. 17. Burn Extent <ul><li>Rule of Palm </li></ul><ul><ul><li>Patient’s palm equals 1% of his body surface area </li></ul></ul>
  18. 18. Burn Severity <ul><li>Based on </li></ul><ul><ul><li>Depth </li></ul></ul><ul><ul><li>Extent </li></ul></ul><ul><ul><li>Location </li></ul></ul><ul><ul><li>Cause </li></ul></ul><ul><ul><li>Patient Age </li></ul></ul><ul><ul><li>Associated Factors </li></ul></ul>
  19. 19. Critical Burns <ul><li>3rd Degree >10% BSA </li></ul><ul><li>2nd Degree > 25% BSA (20% pediatric) </li></ul><ul><li>Face, Feet, Hands, Perineum </li></ul><ul><li>Airway/Respiratory Involvement </li></ul><ul><li>Associated Trauma </li></ul><ul><li>Associated Medical Disease </li></ul><ul><li>Electrical Burns </li></ul><ul><li>Deep Chemical Burns </li></ul>
  20. 20. Moderate Burns <ul><li>3rd Degree 2 to 10% </li></ul><ul><li>2nd Degree 15 to 25% (10 to 20% pediatric) </li></ul>
  21. 21. Minor Burns <ul><li>3rd Degree <2% </li></ul><ul><li>2nd Degree <15% (<10% pediatric) </li></ul>
  22. 22. Associated Factors <ul><li>Patient Age </li></ul><ul><ul><li>< 5 years old </li></ul></ul><ul><ul><li>> 55 years old </li></ul></ul><ul><li>Burn Location </li></ul><ul><ul><li>Circumferential burns of chest, extremities </li></ul></ul>
  23. 23. MANAGEMENT of Burned Patients
  24. 24. Stop Burning Process <ul><li>Remove patient from source of injury </li></ul><ul><li>Remove clothing unless stuck to burn </li></ul><ul><li>Cut around clothing stuck to burn, leave in place </li></ul>
  25. 25. Assess Airway/Breathing <ul><li>Start oxygen if: </li></ul><ul><ul><li>Moderate or critical burn </li></ul></ul><ul><ul><li>Decreased level of consciousness </li></ul></ul><ul><ul><li>Signs of respiratory involvement </li></ul></ul><ul><ul><li>Burn occurred in closed space </li></ul></ul><ul><ul><li>History of CO or smoke exposure </li></ul></ul><ul><li>Assist ventilations as needed </li></ul>
  26. 26. Assess Circulation <ul><li>Check for shock signs /symptoms </li></ul>Early shock seldom results from effects of burn itself. Early shock = Another injury until proven otherwise
  27. 27. Obtain History <ul><li>How long ago? </li></ul><ul><li>What has been done for pt.? </li></ul><ul><li>What caused burn? </li></ul><ul><li>Burned while in confined space? </li></ul><ul><li>Loss of consciousness? </li></ul><ul><li>Allergies/medications? </li></ul><ul><li>Past medical history? </li></ul>
  28. 28. Rapid Physical Exam <ul><li>Check for other injuries </li></ul><ul><li>Rapidly estimate burned, unburned areas </li></ul><ul><li>Remove constricting bands </li></ul>
  29. 29. Treat Burn Wound <ul><li>Cover with DRY, CLEAN SHEETS </li></ul><ul><li>Do NOT rupture blisters </li></ul><ul><li>Do NOT put goo, butter, oil or grease of any kind on the burn </li></ul>
  30. 30. IV Fluid Replacement <ul><li>Parkland formula </li></ul><ul><li>4cc X KG X %(2 nd /3 rd burn) = total cc’s to be infused </li></ul><ul><li>½ will be given in 1 st 8 hours, from time of burn. </li></ul><ul><li>¼ will be given in the 2 nd 8 hours </li></ul><ul><li>¼ will be given in the 3 rd 8 hours </li></ul>
  31. 31. Special Considerations <ul><li>Pediatrics </li></ul><ul><li>Geriatrics </li></ul><ul><li>Location of burn </li></ul>
  32. 32. Pediatrics <ul><li>Thin skin, increased severity </li></ul><ul><li>Large surface to volume ratio </li></ul><ul><li>Poor immune response </li></ul><ul><li>Small airways, limited respiratory reserve capacity </li></ul><ul><li>Consider possibility of abuse </li></ul>
  33. 33. Geriatrics <ul><li>Thin skin, poorly circulation </li></ul><ul><li>Underlying disease processes </li></ul><ul><ul><li>Pulmonary </li></ul></ul><ul><ul><li>Peripheral vascular </li></ul></ul><ul><li>Decreased cardiac reserve </li></ul><ul><li>Decreased immune response </li></ul>
  34. 34. Inhalation Injury
  35. 35. Problems <ul><li>Hypoxia </li></ul><ul><li>Carbon monoxide toxicity </li></ul><ul><li>Upper airway burn </li></ul><ul><li>Lower airway burn </li></ul>
  36. 36. Carbon Monoxide <ul><li>Product of incomplete combustion </li></ul><ul><li>Colorless, odorless, tasteless </li></ul><ul><li>Binds to hemoglobin 200x stronger than oxygen </li></ul><ul><li>Headache, nausea, vomiting, “roaring” in ears </li></ul>
  37. 37. Upper Airway Burn <ul><li>True Thermal Burn </li></ul><ul><li>Danger Signs </li></ul><ul><ul><li>Neck, face burns </li></ul></ul><ul><ul><li>Singing of nasal hairs, eyebrows </li></ul></ul><ul><ul><li>Tachypnea, hoarseness, drooling </li></ul></ul><ul><ul><li>Red, dry oral/nasal mucosa </li></ul></ul>
  38. 38. Lower Airway Burn <ul><li>Chemical Injury </li></ul><ul><li>Danger Signs </li></ul><ul><ul><li>Loss of consciousness </li></ul></ul><ul><ul><li>Burned in a closed space </li></ul></ul><ul><ul><li>Tachypnea (+/-) </li></ul></ul><ul><ul><li>Cough </li></ul></ul><ul><ul><li>Rales, wheezes, rhonchi </li></ul></ul><ul><ul><li>Carbonaceous sputum </li></ul></ul>
  39. 39. Chemical Burns
  40. 40. Concerns <ul><li>Damage to skin </li></ul><ul><li>Absorption of chemical; systemic toxic effects </li></ul><ul><li>Avoiding personal exposure and exposure to crew / hospital. </li></ul>
  41. 41. Management <ul><li>Remove chemical from skin </li></ul><ul><li>Liquids </li></ul><ul><ul><li>Flush with water </li></ul></ul><ul><li>Dry chemicals </li></ul><ul><ul><li>Brush away </li></ul></ul><ul><ul><li>Flush what remains with water </li></ul></ul>
  42. 42. Chemical in Eyes <ul><li>Flush with copious amounts of NS or Ringers </li></ul><ul><li>Don’t put other chemicals in eye </li></ul><ul><li>Flush out contacts </li></ul>
  43. 43. Electrical Burns
  44. 44. Considerations <ul><li>Intensity of current </li></ul><ul><li>Duration of contact </li></ul><ul><li>Kind of current (AC or DC) </li></ul><ul><li>Width of current path </li></ul><ul><li>Types of tissues exposed (resistance) </li></ul>
  45. 45. Voltage Voltage Does Not Kill Current Kills
  46. 46. Electrical Burns <ul><li>Conductive injuries </li></ul><ul><ul><li>“Tip of Iceberg” </li></ul></ul><ul><ul><li>Entrance/exit wounds may be small </li></ul></ul><ul><ul><li>Massive tissue damage between entrance/exit </li></ul></ul>
  47. 47. Other Complications <ul><li>Cardiac arrest/arrhythmias </li></ul><ul><li>Respiratory arrest </li></ul><ul><li>Spinal fractures </li></ul><ul><li>Long bone fractures </li></ul>
  48. 48. Management <ul><li>Make sure current is off! </li></ul><ul><li>Check ABCs </li></ul><ul><li>Assess carefully for other injuries </li></ul><ul><li>Patient needs hospital evaluation, observation </li></ul>
  49. 49. Burn References <ul><li>Mosby’s “Paramedic Textbook” Revised Second Edition - 2001 Chapter 21 Burns </li></ul><ul><li>Mick J. Sanders </li></ul><ul><li>Flight Nursing - Principles & Practice – 1991 </li></ul><ul><li>Genell Lee </li></ul>

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