1. 1 BURNS Temple College EMS Professions

2. 2 Anatomy of Skin l Largest body organ l More than just a passive covering

3. 3 Skin Functions l Sensation l Protection l Temperature regulation l Fluid retention

4. 4 Anatomy l Two layers Epidermis Dermis

5. 5 Epidermis l Outer layer l Top (stratum corneum) consists of dead, hardened cells l Lower epidermal layers form stratum corneum and contain protective pigments

6. 6 Dermis l Elastic connective tissue l Contains specialized structures Nerve endings Blood vessels Sweat glands Sebaceous (oil) glands Hair follicles

7. 7 Burn Epidemiology l 2,500,000/year l 100,000 hospitalized l 12,000 deaths Third leading cause of trauma deaths

8. 8 Pathophysiology l Loss of fluids l Inability to maintain body temperature l Infection

9. 9 Critical Factors l Depth l Extent

10. 10 Burn Depth l First Degree (Superficial) Involves only epidermis Red Painful Tender Blanches under pressure Possible swelling, no blisters Heal in ~7 days

11. 11 Burn Depth l Second Degree (Partial Thickness) Extends through epidermis into dermis Salmon pink Moist, shiny Painful Blisters may be present Heal in ~7 to 21 days

12. 12 Burn Depth l Burns that blister are second degree. l But all second degree burns don’t blister.

13. 13 Burn Depth l Third Degree (Full Thickness) Through epidermis, dermis into underlying structures Thick, dry Pearly gray or charred black May bleed from vessel damage Painless Require grafting

14. 14 Burn Depth l Often cannot be accurately determined in acute stage l Infection may convert to higher degree l When in doubt, over-estimate

15. 15 Burn Extent Rule of Nines

16. 16 Burn Extent l Adult Rule of Nines 9 9 9 18 1 18, Front 18, Back

17. 17 Burn Extent l Pediatric Rule of Nines 18 9 9 13.5 1 18, Front 18, Back For each year over 1 year of age, subtract 1% from head, add equally to legs.

18. 18 Burn Extent l Rule of Palm Patient’s palm equals 1% of his body surface area

19. 19 Burn Severity l Based on Depth Extent Location Cause Patient Age Associated Factors

20. 20 Critical Burns l 3rd Degree >10% BSA l 2nd Degree > 25% BSA (20% pediatric) l Face, Feet, Hands, Perineum l Airway/Respiratory Involvement l Associated Trauma l Associated Medical Disease l Electrical Burns l Deep Chemical Burns

21. 21 Moderate Burns l 3rd Degree 2 to 10% l 2nd Degree 15 to 25% (10 to 20% pediatric)

22. 22 Minor Burns l 3rd Degree <2% l 2nd Degree <15% (<10% pediatric)

23. 23 Associated Factors l Patient Age < 5 years old > 55 years old l Burn Location Circumferential burns of chest, extremities

24. 24 MANAGEMENT

25. 25 Stop Burning Process l Remove patient from source of injury l Remove clothing unless stuck to burn l Cut around clothing stuck to burn, leave in place

26. 26 Assess Airway/Breathing l Start oxygen if: Moderate or critical burn Decreased level of consciousness Signs of respiratory involvement Burn occurred in closed space History of CO or smoke exposure l Assist ventilations as needed

27. 27 Assess Circulation l Check for shock signs /symptoms Early shock seldom results from effects of burn itself. Early shock = Another injury until proven otherwise

28. 28 Obtain History l How long ago? l What has been done? l What caused burn? l Burned in closed space? l Loss of consciousness? l Allergies/medications? l Past medical history?

29. 29 Rapid Physical Exam l Check for other injuries l Rapidly estimate burned, unburned areas l Remove constricting bands

30. 30 Treat Burn Wound l Cover with DRY, CLEAN SHEETS l Do NOT rupture blisters l Do NOT put goo on burn

31. 31 Special Considerations l Pediatrics l Geriatrics

32. 32 Pediatrics l Thin skin, increased severity l Large surface to volume ratio l Poor immune response l Small airways, limited respiratory reserve capacity l Consider possibility of abuse

33. 33 Geriatrics l Thin skin, poorly circulation l Underlying disease processes Pulmonary Peripheral vascular l Decreased cardiac reserve l Decreased immune response

34. 34 Geriatrics l Percent mortality = Age + % BSA Burned

35. 35 Inhalation Injury

36. 36 Problems l Hypoxia l Carbon monoxide toxicity l Upper airway burn l Lower airway burn

37. 37 Carbon Monoxide l Product of incomplete combustion l Colorless, odorless, tasteless l Binds to hemoglobin 200x stronger than oxygen l Headache, nausea, vomiting, “roaring” in ears

38. 38 Carbon Monoxide Exposure makes pulse oximeter data meaningless!

39. 39 Upper Airway Burn l True Thermal Burn l Danger Signs Neck, face burns Singing of nasal hairs, eyebrows Tachypnea, hoarseness, drooling Red, dry oral/nasal mucosa

40. 40 Lower Airway Burn l Chemical Injury l Danger Signs Loss of consciousness Burned in a closed space Tachypnea (+/-) Cough Rales, wheezes, rhonchi Carbonaceous sputim

41. 41 Chemical Burns

42. 42 Concerns l Damage to skin l Absorption of chemical; systemic toxic effects l Avoiding EMS personnel exposure

43. 43 Management l Remove chemical from skin l Liquids Flush with water l Dry chemicals Brush away Flush what remains with water

44. 44 Special Concerns l Phenol Not water soluble Flush with alcohol l Sodium/Potassium Explode on water contact Cover with oil

45. 45 Special Concerns l Tar Use cold packs to solidify tar Do NOT try to remove Tar can be dissolved with organic solvents later

46. 46 Chemical in Eyes l Flush with NS or Ringers l No other chemicals in eye l Flush out contacts

47. 47 Electrical Burns

48. 48 Considerations l Intensity of current l Duration of contact l Kind of current (AC or DC) l Width of current path l Types of tissues exposed (resistance)

49. 49 Voltage Voltage Does Not Kill Current Kills

50. 50 Electrical Burns l Conductive injuries “Tip of Iceberg” Entrance/exit wounds may be small Massive tissue damage between entrance/exit

51. 51 Electrical Burns l Nonconductive injuries Arc burns Ignition of clothing

52. 52 Other Complications l Cardiac arrest/arrhythmias l Respiratory arrest l Spinal fractures l Long bone fractures

53. 53 Management l Make sure current is off! l Check ABCs l Assess carefully for other injuries l Patient needs hospital evaluation, observation