Burns Bledsoe et al Paramedic Care Principles Practice

Burns Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction to Burn Injuries (1 of 2) 1. 25– 2 million Americans treated for burns annually. – – 45, 000 require hospitalization. 90% of burns can be prevented. 3– 5% considered life threatening. 2 nd leading cause of death for children <12. – Half of all tap-water burns occur to children <5. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction to Burn Injuries (2 of 2) Greatest Risk – – – Very young and very old Infirm Firefighters Metal smelters Chemical workers Drugs and alcohol play major role Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Reduction in Burn Injuries Improved building codes Safer construction techniques Sprinkler systems Use of smoke detectors Educational campaigns aimed primarily at school children Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Skin (1 of 2) Layers – – Epidermis Dermis Subcutaneous Underlying structures Fascia Nerves Tendons Ligaments Muscles Organs Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Skin (2 of 2) 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 Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology (1 of 4) Emergent Phase (Stage 1) – Pain response – Catecholamine release Tachycardia Tachypnea Mild hypertension Mild anxiety Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology (2 of 4) Fluid Shift Phase (Stage 2) – Length 18– 24 hours – Begins after emergent phase Reaches peak in 6– 8 hours – Damaged cells initiate inflammatory response: Vasodilation Increased capillary permeability Intravascular hypovolemia Extravascular edema Burns over 30% BSA present with systemic immune response. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of Burns Types of Burns – – Thermal Electrical Chemical Radiation Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Thermal Burns (1 of 2) Heat changes the molecular structure of tissue. – Denatures proteins Extent of burn damage depends on: – Temperature of agent – Concentration of heat – Duration of contact Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Thermal Burns (2 of 2) Jackson’s Theory of Thermal Wounds – Zone of Coagulation Area in a burn nearest the heat source that suffers the most damage as evidenced by clotted blood and thrombosed blood vessels – Zone of Stasis Area surrounding zone of coagulation characterized by decreased blood flow – Zone of Hyperemia Peripheral area around burn that has an increased blood flow Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Jackson’s Theory of Thermal Wounds Zone of Hyperemia Zone of Stasis Zone of Coagulation Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Electrical Burns (1 of 5) Terminology – Voltage Difference of electrical potential between two points Different concentrations of electrons – Amperes Strength of electrical current – Resistance (Ohms) Opposition to electrical flow Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Electrical Burns (2 of 5) Ohm’s Law V=IR – V: Voltage – R: Resistance – I: Current I=V R Based on electron flow through Tungsten – Emit more light the more current passed through Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Electrical Burns (3 of 5) Joule’s Law – P: Power – R: Resistance – I: Current 2 P=I R Skin is resistant to electrical flow: – Greater the current the greater the flow through the body and the greater the release of heat Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Electrical Burns (4 of 5) 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 Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Electrical Burns (5 of 5) Electrical Current Flow – Tissue of less resistance Blood vessels Nerve – Tissue of greater resistance Muscle Bone Results in: – Serious vascular and nervous injury – Immobilization of muscles – Flash burns Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chemical Burns Chemicals destroy tissue: – Acids Form a thick, insoluble mass where they contact tissue Coagulation necrosis Limits burn damage – Alkalis Destroy cell membrane through liquefaction necrosis Deeper tissue penetration and deeper burns Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Radiation Injury Radiation – Transmission of energy Nuclear energy Ultraviolet light Visible light Heat Sound X-rays Radioactive Substance – Emits ionizing radiation – Radionuclide or radioisotope Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Radiation Injury Basic Physics (1 of 2) Protons – Positive charged particles Neutrons – Equal in mass to protons – No electrical charge Electrons – Minute electrically charged particles – When emitted from radioactive substances are termed beta particles Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Radiation Injury Basic Physics (2 of 2) Isotopes – Atoms with unstable nuclear composition Ionizing Radiation Half-life – Time required for half the nuclei to lose activity through decay Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Types of Radiation Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Radiation Injury Radioactive Substances (1 of 2) Alpha Particles – Slow moving – Low energy – Stopped by clothing and paper – Penetrate a few cell layers on skin – Minor external hazard – HARMFUL if ingested Beta Particles – Smaller than alpha – Higher energy than alpha – Stopped by aluminum or similar materials – Less local damage than alpha – HARMFUL if inhaled or ingested Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Radiation Injury Radioactive Substances (2 of 2) Gamma Rays – Highly energized – Penetrate deeper than alpha or beta – EXTREMELY DANGEROUS – Penetrate thick shielding – Pass entirely through clothing and body Extensive cell damage – Indirect damage Cause internal tissue to emit alpha and beta particles Neutrons – More penetrating than other radiation 3– 10 times greater penetration than gamma – Less internal hazard when ingested than alpha or beta – Direct tissue damage – Only present in nuclear reactor core – LEAD SHIELDING Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Radiation Injury Effects on Body Geiger counter needed to detect – R/hr: Milliroentgens per hour 1, 000 m. R = 1 R RAD – Radiation absorbed dose of local tissue REM – Roentgen equivalent in man – Injury to irradiated part of organism – RAD=REM for all purposes Alters body’s cell DNA Cumulative damage over lifetime exposure Decreased WBCs Acute – Effects in minutes to weeks Long-term effects – Years or decades later Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Radiation Injury Safety TIME DISTANCE Clean Accident – Exposed to radiation – Not contaminated by products – Properly decontaminated Little danger to personnel Dirty Accident SHEILDING – Associated with fire at scene of radiation accident – Trained decontamination personnel Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Radiation Injury Management Park upwind. Notify radiation response or hazmat response team. Look for radioactive placards. Measure radioactivity. Decontaminate patients before care. Routine medical care (ABCs, etc. ). Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Inhalation Injury Toxic Inhalation – Synthetic resin combustion Cyanide and hydrogen sulfide Systemic poisoning More frequent than thermal inhalation burn Carbon Monoxide Poisoning – Colorless, odorless, tasteless gas – Byproduct of incomplete combustion of carbon products Suspect with faulty heating unit Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pulse Oximetry Clinical assessment of hypoxia is very difficult in the prehospital setting. – Cyanosis typically occurs with O 2 saturation <70%. May be falsely positive in the patient with significant blood loss or CO poisoning. – 200 x greater affinity for hemoglobin than oxygen Hypoxemia and hypercarbia Measures hemoglobin saturation, NOT Oxygenation Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Inhalation Injury (1 of 2) Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Inhalation Injury (2 of 2) 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 Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Burn Depth (1 of 4) Superficial Burn Partial-Thickness Burn Full-Thickness Burn Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Burn Depth (2 of 4) Superficial Burn: 1 st Degree Burn – Red – Painful – Dry (no blisters) Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Burn Depth (3 of 4) Partial-Thickness Burn: 2 nd Degree Burn – Red or White – Painful – Blisters (wet) Ultraviolet keratitis should be suspected in welders. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Burn Depth (4 of 4) Full-Thickness Burn: 3 rd Degree Burn – Leathery skin White Dark brown Charred – Minimally painful – Dry Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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 Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Rule of Nines Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Rule of Palms A burn equivalent to the size of the patient’s hand is equal to 1% body surface area (BSA). Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Systemic Complications (1 of 2) Hypothermia – Disruption of skin and its ability to thermoregulate Hypovolemia – Shift in proteins, fluids, and electrolytes to the burned tissue – General electrolyte imbalance Eschar – Hard, leathery product of a deep full-thickness burn – Dead and denatured skin Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Systemic Complications (2 of 2) Infection – Greatest risk of burn is infection Organ Failure – Release of myoglobin Special Factors – Age and health Physical Abuse – Elderly, infirm, or young Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment of Thermal Burns (1 of 5) Scene Size-up – Fire department SCBA and protective clothing Initial Assessment – ABCs MUST be intact Consider ET or RSI – Rapid evacuation of patient if scene is unstable Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment of Thermal Burns (2 of 5) 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 Any burn to the face, hands, feet, joints, or genitalia considered a serious burn “Ringing” burns Age of patient affected Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment of Thermal Burns (3 of 5) General Signs and Symptoms Pain Changes in skin condition at affected site Adventitious sounds Blisters Sloughing of skin Hoarseness Dysphagia Dysphasia Burnt hair Edema Paresthesia Hemorrhage Other soft-tissue injury Musculoskeletal injury Dyspnea Chest pain Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment of Thermal Burns (4 of 5) Burn Severity Minor Superficial Partial Thickness Full Thickness <50% BSA <15% BSA <2% BSA Moderate Superficial Partial Thickness Full Thickness >50% BSA >15% BSA >2% BSA Critical Partial Thickness Full Thickness Inhalation Injury >30% BSA >10% BSA Any partial- or full-thickness burn involving hands, feet, joints, face, or genitalia Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment of Thermal Burns (5 of 5) Ongoing Assessment – Non-critical: Reassess Q 15 min. – Critical: Reassess Q 5 min. Burn Center Care Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of Thermal Burns (1 of 5) 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) Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of Thermal Burns (2 of 5) Moderate to Severe Burns – Dry sterile dressings: Partial thickness: >15% BSA Full thickness: >5% BSA – Maintain warmth. Prevent hypothermia. – Consider aggressive fluid therapy. Moderate to severe burns. – Burns over IV sites: Place IV in partial-thickness burn site. – Consider analgesics. Morphine sulfate Fentanyl (Sublimaze) Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of Thermal Burns (3 of 5) Parkland Formula – 4 m. L X weight X % burn – ½ volume in first 8 hours – Second ½ over last 16 hours Consider 1 hour dose 0. 5 m. L x Pt wt in kg x % BSA = Amt of fluid Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of Thermal Burns (4 of 5) Moderate to Severe Burns – Caution for fluid overload. Frequent auscultation of breath sounds – Consider analgesic for pain. Morphine Fentanyl – Prevent infection. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of Thermal Burns (5 of 5) Inhalation Injury – – Provide high-flow O 2 by NRB. Consider intubation if swelling. Consider hyperbaric oxygen therapy. Cyanide exposure: Sodium nitrite, amyl nitrite, sodium thiosulfate Forms methemoglobin which binds cyanide Non-toxic substance secreted in urine Inhale 1 ampule of amyl nitrite 300 mg sodium nitrite over 2– 4 minutes 12. 5 gm of sodium thiosulfate Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment and Management of Electrical, Chemical, and Radiation Burns (1 of 7) 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. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment and Management of Electrical, Chemical, and Radiation Burns (2 of 7) Entrance and exit wounds. Remove clothing, jewelry, and leather items. Treat any visible injuries. – Thermal burns ECG monitoring: – Bradycardia, tachycardia, VF or asystole: ACLS protocols – Treat cardiac and respiratory arrest. – Aggressive airway, ventilation, and circulatory management. Consider fluid bolus for serious burns. – 20 ml/kg Consider sodium bicarbonate: 1 m. Eq/kg. Consider mannitol: 10 g. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment and Management of Electrical, Chemical, and Radiation Burns (3 of 7) 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 Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment and Management of Electrical, Chemical, and Radiation Burns (4 of 7) 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. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment and Management of Electrical, Chemical, and Radiation Burns (5 of 7) Sodium – Unstable metal. – Reacts vigorously with water. Releases Extreme heat Hydrogen gas Ignition – Decontaminate: Brush off dry chemical. – Cover the wound with oil substance. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment and Management of Electrical, Chemical, and Radiation Burns (6 of 7) 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. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment and Management of Electrical, Chemical, and Radiation Burns (7 of 7) 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. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Radiation Injury Whole Body Exposure RAD vs. Body Effects Effect (RAD) 5 -25 Asymptomatic 50 -75 Asymptomatic, WBC changes 75 -125 Anorexia, N/V, and fatigue in 2 days 125 -200 N/V, diarrhea, anxiety, tachycardia N/V, diarrhea, weakness and fatigue in hours 200 -600 50% fatal within 6 weeks without medical care 6001, 000 N/V, diarrhea in hours 100% fatal within two weeks with medical care 1, 000+ Burning sensation in minutes, N/V in 10 min Confusion, ataxia, watery diarrhea in 2 hrs 100% fatal in short time Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Radiation Injury Local Exposure (RAD) vs. Local Effects (RAD) Effect 50 Asymptomatic 500 Asymptomatic (usually), altered function of exposed area 2, 500 Atrophy, vascular lesion, altered pigment 5, 000 Chronic ulcer, risk of cancer 50, 000 Permanent destruction of exposed tissue Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment and Management of Electrical, Chemical, and Radiation Burns Ongoing Assessment – Re-evaluate initial assessment. – Re-evaluate all interventions. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ