0. International Trauma Life Support, 7e
Burns 16
Key Lecture Points
Review the types and classifications of burns.
Discuss the management of different types of burns. Note should be made that while the burns should be cooled briefly to control ongoing heat injury, burns should not be subjected to prolonged cold exposure due to the risk of hypothermia.
Discuss the complications of major burns, such as airway compromise and later fluid loss.
Discuss the need to consider the mechanism of injury, especially with regard to the potential for carbon monoxide or other toxic gas inhalation. A note should be made as to whether this injury occurred in an enclosed space.
Stress the need for maintaining body temperature.
Discuss the treatment of carbon monoxide poisoning. Unless otherwise indicated, 100% oxygen should be used in the major burn patient until he can be further evaluated.
Discuss the findings that suggest inhalation injury and stress that the rescuer must always be alert to this injury.
Stress that the rescuer should record the time that the burn occurred.
Review chemical burns and how their treatment differs from thermal burns.
Review electrical burns and lightning burns and discuss their treatment.
Stress the danger of becoming a victim when dealing with electrical burns.
Mention that the rescuers should be alert to the signs of child abuse when dealing with burned children.

1. Burns
Courtesy of Roy Alson, MD

2. Overview Basic anatomy and functions of skin Severity of burns
Epidermal, dermal layers and structures
Severity of burns
Appearance, depth
Extent of burn using Rule of Nines
NOTE: Review anatomy of skin and how damage to this organ can cause extensive problems after a burn, including shock and sepsis.
Resuscitation of burn patient focuses on 2 key areas:
Early deaths are due to airway injury, smoke inhalation and toxin exposure.
Later deaths are due to shock from fluid loss.
Determination of extent of burns can help guide resuscitation and also help identify those patients who would benefit from treatment at a burn center, if one is available.
Review factors that make chemical and electrical burns different from thermal injury.

3. Overview Complications and management:
Thermal, chemical, and electrical burns
Carbon monoxide poisoning and inhalation injury
Burn center guidelines
NOTE: Review anatomy of skin and how damage to this organ can cause extensive problems after a burn, including shock and sepsis.
Resuscitation of burn patient focuses on 2 key areas:
Early deaths are due to airway injury and smoke/ toxin inhalation.
Later deaths are due to shock from fluid loss.
Determination of extent of burns can help guide resuscitation and also help identify those patients who would benefit from treatment at a burn center, if one is available.
Review factors that make chemical and electrical burns different from thermal injury.

4. Burns Safety is extremely important
Scene Size-up, rescue or removal
Multiple agents cause burn injuries
Pathologic damage to skin is similar
Many deaths from burns, and many who survive their burns are left severely disabled and/or disfigured.
According to American Burn Association, there are more than 1 million burn injuries per year in the United States, resulting in more than 4,500 deaths. Thousands more are injured. While number of those killed or injured has decreased in last 30 years, particularly with use of smoke detectors and improvements in burn care, burn injury is still a major problem for our society.
Applying basic principles taught here can help decrease death, disability, and disfigurement from burn injuries.

5. Functions of Skin Largest organ Functions: Mechanical barrier
Protective barrier
Sensory organ
Temperature regulation
IMAGE: Figure 16-1 Point out skin layers and structures. New skin cell growth occurs in lower portion of dermis.
Largest organ of body—the skin—is made up of 2 layers:
Outer layer is epidermis—serves as a barrier between environment and our body.
Dermis is thick layer of collagen connective tissue underneath thin epidermis.
Contains important sensory nerves and also support structures such as hair follicles, sweat glands, and oil glands.
Skin has many important functions:
Acts as a mechanical and protective barrier between body and outside world.
Seals fluids inside.
Prevents bacteria and other microorganisms from readily entering body.
Skin is also a vital sensory organ that provides input to brain on general and specific environmental data and serves a primary role in temperature regulation.

6. Burn Trauma Skin damage Sources of damage
Direct injury from heat or caustic chemicals
Inflammatory response
Sources of damage
Thermal
Electrical
Chemical
Radiation
IMAGE: Full-thickness burn of upper body.
Burn damage to skin occurs when heat or caustic chemicals come in contact with skin and damage its chemical and cellular components.
In addition to actual tissue injury, body's inflammatory response to skin damage may result in additional injury or increase severity of a burn.
© Edward T. Dickinson, MD

7. Burn Classification Depth of burn Extent of burn
Superficial (first degree)
Partial-thickness (second degree)
Full-thickness (third degree)
Extent of burn
Rule of Nines
Lund and Browder
Palmar surface
NOTE: Overview of next several slides.
Burns are characterized, based on depth of tissue damage and skin response, as superficial (first degree), partial thickness (second degree), or full thickness (third degree).

8. Burn Depth Superficial Management
Minor tissue damage to outer epidermal layer
Intense and painful inflammatory response
“Sunburn”
Management
Symptomatic treatment
IMAGE: Figure 16-2 Superficial burn.
Superficial burns result in minor tissue damage to outer epidermal layer only, but do cause an intense and painful inflammatory response. Most common injury of this type is “sunburn.”
Although no medical treatment is usually required, various medications can be prescribed that significantly speed healing and reduce painful inflammatory response.

9. Burn Depth Partial-thickness Management
Entire epidermis into variable depth of dermis
Usually no scarring
Management
Cool burn and cover with clean, dry dressing
Often antibiotic creams
IMAGE: Figure 16-3 Partial-thickness burn.
Partial-thickness burns cause damage through epidermis and into a variable depth of dermis.
Will usually heal without scarring, because cells lining deeper portions of hair follicles and sweat glands will multiply and grow new skin for healing.
Antibiotic creams or various specialized types of dressings are routinely used to treat these burns and, therefore, appropriate medical evaluation and care should be provided for patients with these injuries.
Emergency care of partial-thickness burns involves cooling burn and covering with a clean, dry dressing.

10. Burn Depth Full-thickness Management Epidermis and dermis
Scars contract, limit motion
Deeper full-thickness
“Leather-like” eschar
Management
Burn center
IMAGE: Figure 16-4 Full-thickness burn.
Full-thickness burns cause damage to all layers of epidermis and dermis. No more skin cell layers are left, so healing by regrowth of epidermal cells is impossible.
All full-thickness burns leave scars that later may contract and limit motion of extremity (or restrict movement of chest wall).
Deeper full-thickness burns usually result in skin protein becoming denatured and hard, forming a firm, leatherlike covering that is referred to as eschar.

11. Burn Depth Characteristics
IMAGE: Table 16-2 Characteristics of Various Depths of Burns.

12. Burn Depth Courtesy of Roy Alson, MD
NOTE: Point out varying levels of burns in images.
IMAGE (child profile): Second- and third-degree burns to child's face, neck, and torso. Consider child neglect or abuse.
IMAGE: Blisters indicate second-degree burn.
IMAGE: A second-degree burn blisters hand of a burn victim.  
Courtesy of Roy Alson, MD
© Pearson

13. Burn Depth IMAGE: Full-thickness burn.
IMAGE: Partial-thickness burn on back.
© Pearson
© Pearson

14. Scald NOTE: Contrast scald burn from falling liquid and immersion.
IMAGE: Pink scald burns on legs of little child—indicates forced immersion (clear line of burn, no splashing). This burn pattern is suspicious for abuse.
Water holds heat and can easily burn skin, especially of young children.
Courtesy of Roy Alson, MD

15. Burn Depth Progression Management Inflammatory response
Extends damage and depth (1–2 days)
Severe fluid loss (hours or days)
Sepsis (days)
Reduced circulation extends depth
Management
Limit progression of depth and extent
Normal inflammatory response to burn injury can result in progressive tissue damage for a day or two following burn injury, which may result in an increase in burn depth.
Any condition that either reduces circulation (shock) to damaged tissue or by itself causes further tissue damage will lead to burn progression with increasing burn depth.
Estimate amount of body surface involved in burn and whether superficial or deep.
It is not essential to determine exactly burn depth in field (due to burn progression).
Transport to a burn center depends on both depth and extent of burn.
Initial care that is directed specifically toward burn should concentrate on limiting any progression of burn depth and extent.

16. Rule of Nines IMAGE: Figure 16-5 Rule of Nines.
Burn size is best estimated in field using Rule of Nines. Body is divided into areas that are either 9% or 18% of total body surface. By roughly drawing in burned areas, extent can be estimated. Only partial-thickness and full-thickness burns are used for this calculation.

17. Lund and Browder Chart
IMAGE: Table 16-3 Lund and Browder Chart. NOTE: Students do not need to read chart on screen.
IMAGE: Figure 16-6 Serious small burns.
In small children there are some differences in body size proportions, and a Lund and Browder chart is helpful.
For smaller or irregular burns, size can be estimated using palmar surface (including fingers) of patient's hand, which is about 1% of total body surface area.
Serious small burns affecting function or appearance are given higher severity. While these areas are included in estimated extent using Rule of Nines, be sure to report that any of these areas are included in burn.

18. Burn Assessment ITLS Primary and Secondary Surveys
Specialized resources
Patient rescue or removal
Safely remove from source
Thermal, chemical, electricity
Toxic by-products, smoke
Death in immediate post-burn period is consequence of associated trauma or conditions such as airway compromise, toxin or smoke inhalation, not from burn injury. Follow ITLS Assessment so as not to miss traumatic injury.
First step in treating a burn patient involves maintaining your safety and safety of your patient. Safely remove patient from source of burn. Specialized equipment and training are essential in many of these cases.
© M. Norris

19. Stop the Burning Process
Animation on mouse click: Octagon appears with message.

20. Burn Management Limit burn progression
Cool skin, clothing with clean water 1–2 minutes
Longer induces hypothermia
Clean, dry sheets, blankets
Sterile sheets not necessary
Maintain body temperature
Prevent hypothermia
Remove wet clothing and items
Once immediate life-threats have been addressed, attend to burn. Initial burn care concentrates on limiting any progression of burn depth and extent.
Try to limit burn wound progression as much as possible. Rapid cooling early in course of a surface burn injury can help limit this progression.
Following removal from source of burn, skin and clothing are still hot, and this heat continues to injure tissues, causing an increase in burn depth and seriousness of injury. Cooling should be done with any source of clean water, for no more than a minute or two. Cooling for longer periods of time can induce hypothermia and subsequent shock.
Following brief period of cooling, manage burn by covering patient with clean, dry sheets and blankets to keep patient warm and to prevent hypothermia. It is not necessary to have sterile sheets. Patient should be covered even when environment is not cold, because damaged skin loses temperature regulation capacity.
Never transport on wet sheets, wet towels, or wet clothing.
Ice is absolutely contraindicated. Ice will worsen injury as it causes vasoconstriction and thus reduces blood supply to already damaged tissue.
Cooling a burn wound improperly can cause hypothermia and additional tissue damage, and could be worse than not cooling burn at all.

21. Burn Assessment Airway Frequent Ongoing Exams Facial and scalp burns
Sooty sputum
Singed nasal hair, eyebrows
Soot, swelling, redness
Hoarse voice, persistent cough
Wheezing or crackles
Frequent Ongoing Exams
Any burn type can have some degree of inhalation injury.
Courtesy of Roy Alson, M.D.

22. Critical Problems Mechanism Management Confined in closed space
Electrical burns
Chemical exposure
Falls from a height
Major blunt-force trauma
Management
High-flow oxygen as soon as possible
Clues from mechanism of injury that point to critical problems include a history of being confined in a closed space with fire or smoke, electrical burns, chemical exposure, falls from a height, or other major blunt-force trauma.
Supplemental oxygen should be initiated as soon as possible for all major burn patients.

23. Early burn deaths: airway compromise, not burn injury.
People do not actually die rapidly from burn injuries. Early burn deaths are usually result of airway or trauma.

24. Burn Management Evaluate burn Large-bore IV access, if needed
Remove loose clothing and jewelry
Cut around adherent clothing; do not pull off of skin
Assess depth and extent
Large-bore IV access, if needed
Pain management
Isolated burns; no coexisting trauma
Controversial in multiple trauma
IV line insertion is rarely needed on-scene during initial care, unless delay in transport to a hospital is unavoidable.
Burn shock takes hours to develop; therefore, only reason to initiate IV is if other factors indicate a need for fluid volume or medication administration.
Attempting to start IV therapy on-scene in major burn patients is often difficult, and routinely delays initial transport and arrival at hospital. IV access may be established during transport.
Pain medication administration in multiple-trauma patient remains controversial.
A risk of masking associated trauma and also both central nervous system and cardiovascular depression are associated with use of pain medication.
In isolated burns without coexisting trauma and long transport times, administration of analgesics in appropriate dosages will improve patient comfort.
Consult medical direction prior to administration of pain medication.

25. Burn Center Guidelines
IMAGE: Table 16-4 Injuries that benefit from care at a burn center.
NOTE: Do not read from the table; direct students to it in the textbook.

26. Specific Burns Multiple burn types can be combined Circumferential
Flash burns
Inhalation injuries
Carbon monoxide
Cyanide & Smoke inhalation
Heat inhalation
Chemical burns
NOTE: Overview of next slides.
Be aware that more than one type of burn can be present in a patient; for example, a high-voltage electrical burn injury may also produce flame burns, due to ignition of patient's clothing.

27. Specific Burns Multiple burn types can be combined Electrical burns
Lightning injury
Radiation burns
Secondary transport
Pediatric burns
NOTE: Overview of next slides.
Be aware that more than one type of burn can be present in a patient; for example, a high-voltage electrical burn injury may also produce flame burns, due to ignition of patient's clothing.

28. Burn Types Circumferential full-thickness burns Management
As edema progresses, may have tourniquet effect
Escharotomy
Management
Monitor respiration and chest expansion
Monitor distal PMS
Circumferential burns: Circumferential full-thickness burns may lead to neurovascular compromise. While this is rarely a problem on fire scene, this may become significant during an interfacility transfer.
Full-thickness burns that are circumferential around an extremity can act as a tourniquet as edema progresses.
Early on, patient may complain of loss of sensation, tingling, and eventually develop ischemic pain with loss of pulses.
Circumferential burns of chest can interfere with chest expansion and thus compromise respirations.
Circumferential full-thickness burns on extremities will require an escharotomy, especially if long transport times are involved.
Be sure to alert receiving facility if you are transporting a patient with full-thickness circumferential burns.

29. Burn Types Flash burn Associated symptoms
Source is explosion, not sustained fire
Superficial or partial-thickness to exposed skin
Full-thickness (rare)
Associated symptoms
Explosion trauma
Fractures
Internal injuries
Blast chest injuries
Flash burns are virtually always superficial or partial-thickness burns.
Occur when there is some type of explosion, but no sustained fire.
Single heat wave traveling out from these explosions results in such short patient–heat contact that full-thickness burns almost never occur.
Only areas directly exposed to true heat wave will be injured. Typically, face and hands are involved.
Other injuries (fractures, internal injuries, blast chest injuries, and so on) may occur as a result of explosion.

30. Burn Types Inhalation injuries Mechanism Classifications
Burn related deaths (U.S.): >50%
Mechanism
Confined space or entrapment
Classifications
Carbon monoxide poisoning
Heat-inhalation
Smoke-inhalation
Inhalation injuries are classified as carbon monoxide poisoning, heat-inhalation injuries, or smoke (toxic) inhalation injuries.
Most frequently, inhalation injuries occur when a patient is injured in a confined space or is trapped; however, even victims of fires in open spaces may have inhalation injuries. Flash explosions (no fire) practically never cause inhalation injuries.
Inhalation injuries account for more than half of 4,500+ burn-related deaths in the United States each year.

31. Inhalation Injuries Carbon monoxide poisoning Associated symptoms
Hypoxia due to hemoglobin binding
Most common cause of early death
Associated symptoms
Altered level of consciousness
Cherry-red skin color or cyanosis (rare)
Pulse oximetry not useful
Progressive cardiac hypoxia
Carbon monoxide poisoning and asphyxiation are by far most common causes of early death associated with burn injury.
Carbon monoxide is a by-product of combustion and is one of numerous chemicals in common smoke. It is present in high concentrations in auto exhaust fumes and fumes from some types of home space heaters. Since it is colorless, odorless, and tasteless, its presence is virtually impossible to detect.
Carbon monoxide binds to hemoglobin (257 times stronger than oxygen), resulting in hemoglobin being unable to transport oxygen. Patients quickly become hypoxic even in presence of low concentrations of carbon monoxide.
An alteration in level of consciousness is predominant sign of this hypoxia.
Pulse oximetry will remain normal to high in presence of carbon monoxide and cannot be used to assess these patients.
Some newer-model pulse oximeters can specifically measure carboxyhemoglobin levels and, if available, should be used on all persons who have possibility of exposure to carbon monoxide.
Death usually occurs because of either cerebral or myocardial ischemia or myocardial infarction due to progressive cardiac hypoxia.

32. Carbon Monoxide Poisoning
IMAGE: Table 16-5 Symptoms Associated with Increasing Levels of Carboxyhemoglobin Binding.
NOTE: Point out symptoms easily confused with other underlying causes. History essential to suspect.

33. Carbon Monoxide Poisoning
Management
Remove from source
Safety
Consider multiple patients
High-flow oxygen
Loss of consciousness: intubation, ventilation
Hyperbaric chamber by medical direction
Treat patients suspected of having carbon monoxide poisoning with high-flow oxygen by mask.
If loss of consciousness, begin Advanced Life Support with intubation and ventilation using 100% oxygen.
Example of time to reduce carbon monoxide–hemoglobin complex to a safe level (from 50% to 20%):
Breathe fresh air: 7 hours
100% oxygen: 90–120 minutes
Hyperbaric oxygen (100% oxygen at 2.5 atmospheres): 30 minutes
All suspected cases of carbon monoxide poisoning or toxic inhalation should be transported to an appropriate hospital. The decision to transport patient to a hyperbaric chamber should be made by medical direction.
Courtesy of Roy Alson, MD

34. Inhalation Injuries Cyanide Management
Highly toxic component when plastic combusts
Prevents the cells from using oxygen
Management
Opinions still vary
IV hydroxocobalamin
Easier to use than previous cyanide kits
In the modern world, many items in homes and businesses are made of plastics. When combusted, many of them give off toxic gases, which can cause significant pulmonary injury.
Among the toxic components in smoke is hydrogen cyanide. It is highly toxic and causes cellular hypoxia by preventing the cell from using oxygen to generate energy to function.
Opinions regarding empirical treatment of smoke inhalation victims for cyanide poisoning still vary.
The current recommended agent for such treatment is IV hydroxocobalamin, which combines with cyanide to form non-toxic cyanocobalamin (vitamin B12).
Hydroxocobalamin is easier and safer to use in the prehospital setting than the previous Lilly or Pasadena cyanide kits.
This is an area of burn management that is continuing to evolve as more research is conducted.

35. Inhalation Injuries Heat-inhalation Associated symptoms Management
Upper airway only
Unless steam or flammable gas
Airway obstruction due to swelling
Onset: delayed
Not usually in field
Associated symptoms
Swollen lips, stridor
Management
Intubation
Sedation, if necessary
Nasotracheal
RSI
Surgical
Avoid aggressive fluid administration
May increase swelling
Heat-inhalation injuries are confined to upper airway, because breathing in flame and hot gases does not result in heat transport down to lung tissue itself. Water vapor in air in tracheal-bronchial tree effectively absorbs this heat.
Exceptions are:
Steam inhalation, as steam is superheated water vapor.
Inhaled flammable gas that then ignites and causes thermal injury to level of alveoli.
Swelling of loose mucosa in supraglottic area (hypopharynx) occurs as a result of heat injury. Vocal cords do not swell because they are dense fibrous bands of connective tissue. Swelling can easily progress to complete airway obstruction and death, but is rare in initial prehospital phase. Be aware that once swelling begins, airway can obstruct rapidly.
Aggressive fluid resuscitation can hasten swelling.
Associated symptoms such as swollen lips indicate presence of thermal injury at airway entrance. Hoarseness is warning sign of early airway swelling.
Stridor indicates severe airway swelling with pending airway obstruction and represents an immediate emergency.
Appropriate treatment is airway stabilization, preferably via nasotracheal intubation or by paralysis and rapid sequence intubation.
Intubation may be far more difficult due to significant anatomic alterations from swelling.
Lethal laryngospasm may occur when endotracheal tube first touches laryngeal area.
Should be done in field only when absolutely necessary following communication and orders from medical direction.
Be prepared to perform a surgical airway in these patients if unable to intubate.

36. Inhalation Injuries Smoke-inhalation Management
Destruction of bronchi and alveoli from toxins
Onset: hours to days
Management
High-flow oxygen
Inhaled beta agonists for bronchospasm
Smoke-inhalation injuries are result of inhaled toxic chemicals that cause structural damage to lung cells.
Smoke may contain hundreds of toxic chemicals that damage delicate alveolar cells.
Smoke from plastic and synthetic products is most damaging.
Tissue destruction in bronchi and alveoli may take hours to days.
Toxic chemicals may precipitate bronchospasm or coronary artery spasm in susceptible individuals.
Treat bronchospasm with inhaled beta agonists (albuterol) and oxygen.

37. Burn Types Chemical burns Tissue damage
Concentration, amount, manner, duration of contact, mechanism of chemical action
Initial skin changes minimal even when severe
Absorbed into body, cause internal organ failure
Inhaled, cause lung tissue, respiratory failure
Onset: systemic, not immediate
Chemical burns: Chemicals not only injure skin, but are also absorbed into body and cause internal organ failure (especially liver and kidney damage).
Volatile forms of chemicals may be inhaled and cause lung tissue damage with subsequent severe life-threatening respiratory failure.
Effects of chemical agents on other organ systems, such as lung or liver, may not be immediately apparent after exposure.
Initial skin changes may be minimal, even when a severe injury is present.
Avoid secondary contamination of rescuers.
Factors that lead to tissue damage include chemical concentration, amount, manner and duration of skin contact, and mechanism of action of chemical agent.

38. Chemical Burns Remove source Protective gear
Remove clothing, place in plastic bags
If dry chemical, brush from skin
Flush copiously with water or irrigant
If eyes, remove contact lenses, foreign bodies
Remove retained agent
Repeat flush
Prevent secondary contamination
Tissue damage continues until chemical is either consumed in damage process, detoxified by body, or physically removed.
Attempts at inactivation with specific neutralizing chemicals are dangerous, because process of neutralization may generate other chemical reactions (heat) that may worsen injury.
Chemical removal—4 steps:
Respiratory protection and/or chemical protective suit, if needed.
Remove all patient's clothing. Place in plastic bags to limit further contact.
Flush chemicals off body by irrigating copiously with any source of available water or other irrigant.
If dry chemicals are on skin, they should first be thoroughly brushed off before performing copious irrigation.
Remove any retained agent adhering to skin by any appropriate physical means, such as wiping or gentle scraping. Repeat flushing of skin.
Ideally, decontaminate prior to transport, so as to limit skin damage and prevent contamination of ambulance or hospital.
Critical interventions, including airway management, can be initiated prior to and during decontamination process.
Irrigation of caustic chemicals in eye is exceptionally important because irreversible damage will occur in a very short period of time.
Irrigation of injured eyes may be difficult because of pain associated with eye opening.
Check for contact lenses or foreign bodies and, if present, remove them early during irrigation.

39. Chemical Burns
IMAGE: Chemical burn to foot—notice area burn was covered by shoe, probably had longer exposure time.
Courtesy of Roy Alson, MD

40. Chemical Burns
IMAGE: Chemical burn to hand: “weird green swelling from hydrofluoric acid.”
IMAGE: Chemical burn to ear.
Courtesy of Roy Alson, MD
Courtesy of Roy Alson, MD

41. Burn Types Electrical burns Mechanism
Electricity effect on organ function
Heat generated by passage of current
Extremities greater risk of injury
Mechanism
Type and amount of current (AC, DC, voltage)
Path of current through body
Duration of contact with current source
Electrical burns cause damage by electricity entering body and traveling through tissues. Injury results from effects of electricity on function of body organs and from heat generated by passage of current.
Extremities are at risk for more significant tissue damage, versus torso, because their small size results in higher local current density.
Factors that determine severity of electrical injury include the following:
Type and amount of current (alternating versus direct current and also voltage).
Path of current through body.
Duration of contact with current source.
With electrical injury, treatment of arrhythmias and/or cardiac arrest following ACLS/ILCOR Guidelines is key to ensuring survival.

42. Electrical Burns Associated symptoms Cardiac arrhythmia
PVCs, ventricular tachycardia, ventricular fibrillation
Entrance and exit wound
Impossible to determine extent
Flame burns
Fractures, dislocations
Internal injuries
Muscle damage, nerve damage, coagulation
Most serious and immediate injury that results from electrical contact is cardiac arrhythmia.
Most common life-threatening arrhythmias are premature ventricular contractions, ventricular tachycardia, and ventricular fibrillation.
All electric current injuries should have careful immediate evaluation of cardiac status and continuous monitoring of cardiac activity.
Aggressive ALS (ACLS/ILCOR Guidelines) management should be undertaken, since chances for resuscitation are excellent.
Most victims do not have preexisting cardiovascular disease, and their heart muscle tissue is usually not damaged as a result of electricity.
After managing cardiac status, provide thermal burn care.
Electrical injuries:
Skin burns at entrance and exit sites and frequently surface flame burns if clothing is ignited.
Fractures and/or dislocations may be present due to violent muscle contractions that electrical injuries cause.
Fractures or other injuries due to falls after an electric shock.
Internal injuries usually involve muscle damage, nerve damage, and possible intravascular blood coagulation due to electrical current passage.
Internal chest or abdominal organ damage due to electrical current is exceedingly rare.

43. Electrical Burns Rhabdomyolysis
Breakdown of muscle releasing myoglobin
Renal failure from blocked tubules
Fluid resuscitation to maintain urine output of 0.5 – 1.0 cc/kg per hour
Electrical burn patients are at risk for developing rhabdomyolysis.
The breakdown of muscle with the release of myoglobin into the circulation and renal failure, as the myoglobin crystals block the kidney tubules.
In those cases, the rule of nines is not applicable and adequate fluid resuscitation is indicated by maintaining a urine output of 0.5 to 1 cc/kg body weight per hour. This level of urine flow also helps to reduce the risk of renal failure from rhabdomyolysis.

44. Electrical Burns Management Safety High-flow oxygen
Transport all electrical injuries
Large-bore IV access
Fluid administration needs often higher than thermal
Cardiac monitor
Treat arrhythmias
First priority is scene safety.
Determine if patient is still in contact with electrical current. If possible, leave handling of downed wires to power company personnel or develop a special training program with your local power company to learn how to use special equipment designed to handle high-voltage lines.
Impossible to tell total extent of damage in electrical burns. So, all electrical burn patients should be transported for hospital evaluation.
Due to potential for arrhythmia development, routine IV access should be initiated in ambulance, along with continuous cardiac monitoring.

45. Electrical Burns
IMAGE: Electrical burn of arm. Notice superficial burns of chest and arm due to clothes ignition.
IMAGE: Electrical burn of feet. Notice areas of varying tissue destruction.
Courtesy of Bonnie Meneely, EMT- P
Courtesy of David Effron, MD

46. Electrical Burns
IMAGE: Charring electrical burn—lacerated leg bone can be seen.
Courtesy of Roy Alson, MD

47. Burn Types Lightning injury Mechanism Associated symptoms Management
Extreme voltage
Short duration
Mechanism
Direct contact
Indirect contact
Associated symptoms
Superficial and partial-thickness burns
Cardiopulmonary arrest
Management
SMR
ACLS
Lightning injury is very different from other electrical injuries in that lightning produces extremely high voltages and currents, but has a very short duration of contact.
Lightning kills more people in North America each year than any other weather- related phenomenon.
Injured by direct or indirect lightning strike:
Adjacent object or nearby ground can still produce an injury to a victim.
May have superficial burns from clothes ignition.
Most serious effect of a lightning strike is cardiorespiratory arrest.
Cardiac activity often spontaneously resumes within minutes.
However, respiratory drive centers of brain take longer to recover and resume normal respiratory drive. Consequently, victim remains in respiratory arrest, which is followed by a second cardiac arrest from hypoxia.
Essential component of management of lightning strike victim is restoration of cardiorespiratory function, while protecting cervical spine.
Follow standard guidelines for CPR and ALS (ACLS/ILCOR Guidelines).
Since lightning strikes can occur at sporting events and other outdoor gatherings, strikes often become multiple-casualty events.
In a multiple-casualty lightning strike, conventional triage approach of a pulseless or nonbreathing patient equaling a dead patient should not be followed. If a patient is awake or breathing after a lightning strike, he will most likely survive without further intervention. Resuscitative efforts should concentrate on those victims who are in respiratory or cardiac arrest, since prompt CPR and ALS represent only chance that these victims have for survival.

48. Lightning Injury
Lightning produces a “flashover” phenomenon, in which current flows around outside of victim's body. Consequently, internal damage from current flow seen with generated electricity is not seen in a lightning strike.
Most of effects from a lightning strike are result of massive DC (direct current) shock that is received.
Classic lightning strike burns produce a fernlike or splatter pattern across skin.
Courtesy of David Effron, MD, FACEP

49. Burn Types Radiation burns Appear same as thermal
Onset: develop over days
Danger of fluid shift
Danger of infection
Need specialized resources
Remove contaminants
Only contaminants are radioactive, not patient
© Pearson
Radiation burns: Ionizing radiation damages cells by breaking molecular bonds. Skin burns from radiation look exactly like thermal burns and cannot be differentiated by their appearance alone.
However, radiation burns develop slowly over days and so generally do not present as an emergency. Because of damage to skin cells, radiation burns heal very slowly. They can cause fluid loss like thermal burns and are even more prone to infection.
Patients with radiation burns are not radioactive unless they are contaminated with radioactive material. If there is any danger of contamination, call for specialized resources.
Noncontaminated radiation-burn patients are treated same as any burn patient.

50. Burn Types Secondary transport Parkland formula
Monitor airway, respiratory, hemodynamic status
Monitor burn and associated injuries
Monitor urinary output (renal function)
Fluid administration
Parkland formula
Fluid required in first 24 hours is: 4 cc/kg x % burn area x body weight (kg)
Secondary transport: Transport from a primary hospital to a burn center is commonly necessary. After initial stabilization, prompt transfer to a burn center can improve patient outcome.
During secondary transport:
Monitor airway, respiratory, hemodynamic status.
Monitor burn and associated injuries.
Monitor urinary output (renal function).
Fluid administration.
Assessment of peripheral circulation (swelling) and appropriate wound management.
Initial resuscitative fluid needs in a burn patient are calculated using Parkland formula: 4 cc/kg of Ringer's lactate or normal saline x % burn area x body weight (kg) = fluid needs in first 24 hours. Half of this fluid is given in first 8 hours, and remainder over next 16 hours.
Fluid resuscitation needed for hypovolemia is not part of the maintenance fluid calculation for burn management
Maintain careful records indicating patient condition and treatment during transport.

51. Burn Types Pediatric burns Mechanism Greater severity Accidental
Thinner skin, larger surface area to body mass ratio
Mechanism
Accidental
Child neglect or abuse
Match object shapes
Clear lines without splatter or splash
History does not match developmental age
Pediatric burns: Due to thinner skin, children are at greater risk for severe injury following a burn. Postburn problems, such as hypothermia, are more likely to occur in children because of their larger surface area to body mass ratio.
Pediatric burn extent: The Rule of Nines must be modified based on differences in anatomy, as in small children head represents a larger portion of body surface. Lund and Browder chart is better for estimating burn size in children. Palmar surface (1%) rule applies to children as well as adults.
Look for signs of abuse. If there is a suspicion of abuse, follow appropriate guidelines for your area.
Burns that match shapes of objects such as curling irons, irons, or cigarette burns.
Multiple stories of how injury occurred or stories of burn being caused by activities by child that are inconsistent with child's development.
Burns to genitalia, perineum, or in a stocking or glove distribution should also raise suspicion.
Fire and EMS personnel can help reduce burns in children through community education.

52. Summary Safety is essential Early deaths are due to airway compromise
Limit progression of depth and extent
Careful, systematic approach:
Identify and manage critical life-threatening problems and improve patient outcome
Key principles:
Extricate victim and protect yourself.
Cool burn if thermal; decon if chemical.
Airway support is key.
Carry out ITLS Survey to identify life threats and treat accordingly.
Consider transport to burn center, if available, and burn severity or associated injury suggests need.
Treatment including airway management, fluid resuscitation, and analgesia is determined by type and extent of burns.