Burns Burns. Burns John van der Steeg MD Objectives Incidence and patterns of burn injury Incidence and patterns of burn injury Pathophysiology of local

BurnsBurns

BurnsBurnsJohn van der Steeg MDJohn van der Steeg MD

ObjectivesObjectives

Incidence and patterns of burn injuryIncidence and patterns of burn injury Pathophysiology of local and systemic Pathophysiology of local and systemic

responses to burn injuryresponses to burn injury Classify burn Classify burn Physical exam of the burned patientPhysical exam of the burned patient Prehospital management of burned patientPrehospital management of burned patient Signs and symptoms of inhalational injury Signs and symptoms of inhalational injury

which may influence managementwhich may influence management Criteria for transport to a Burn CenterCriteria for transport to a Burn Center

Incidence and Pattern of Burn Incidence and Pattern of Burn TypesTypes

Tissue injury caused by thermal, electrical, Tissue injury caused by thermal, electrical, radiation or chemical agentsradiation or chemical agents

Burns are another form of traumaBurns are another form of trauma Associated with high mortality, lengthy Associated with high mortality, lengthy

rehabilitation.rehabilitation. Greater than 2 million people/yr. seek care Greater than 2 million people/yr. seek care

for burns.for burns. Morbidity and Mortality follow significant Morbidity and Mortality follow significant

patterns regarding gender, age, and patterns regarding gender, age, and socioeconomic status socioeconomic status

SkinSkin

Largest body organ.Largest body organ. Not a passive organ.Not a passive organ.

– Protects underlying tissues from injuryProtects underlying tissues from injury– Temperature regulationTemperature regulation– Acts as water tight sealActs as water tight seal– Sensory organSensory organ

Very young and old have thin skin Very young and old have thin skin thus short contact time = greater thus short contact time = greater damage when compared to mid aged damage when compared to mid aged personspersons

Skin concerns after burnsSkin concerns after burns

InfectionInfection

Problems with thermal regulationProblems with thermal regulation

Inability to maintain normal water Inability to maintain normal water balancebalance

Skin layersSkin layers

Two layers Two layers – EpidermisEpidermis– DermisDermis

EpidermisEpidermis– Outer cells are deadOuter cells are dead– Protective barrier and Protective barrier and

water tight sealwater tight seal– Deeper layers contain Deeper layers contain

pigment to protect pigment to protect against UV radiation against UV radiation and produce stratum and produce stratum corneumcorneum

Skin LayersSkin Layers

DermisDermis– Consists of tough, Consists of tough,

elastic tissue which elastic tissue which contains specialized contains specialized structures such as structures such as hair follicles, sweat hair follicles, sweat glands, blood glands, blood vessels, oil glands, vessels, oil glands, and nerve endingsand nerve endings

Classification of BurnsClassification of Burns

First degree / First degree / superficial burn- superficial burn- painful, red, and painful, red, and dry and blanch dry and blanch with pressure. with pressure.


22ndnd degree / partial degree / partial thickness burn- thickness burn- characterized by characterized by blisters, injury blisters, injury extends through extends through the dermis to the the dermis to the epidermis, basal epidermis, basal layers of skin are layers of skin are not destroyednot destroyed


33rdrd degree / full degree / full thickness burns- Entire thickness burns- Entire thickness of dermis thickness of dermis and epidermis is and epidermis is destroyed. Wound destroyed. Wound characterized by characterized by coagulatin necrosis coagulatin necrosis and appears pearly and appears pearly white, charred or white, charred or leathery. Sensation leathery. Sensation and cap refill are and cap refill are absent.absent.

Factors which affect Burn Factors which affect Burn injuryinjury

Water contentWater content Skin thicknessSkin thickness Skin pigmentSkin pigment Presence of absence of insulating Presence of absence of insulating

substancessubstances Peripheral circulationPeripheral circulation

Tissue damage depends on Tissue damage depends on temperature and timetemperature and time

Surface temperature of 44 C (111 F) Surface temperature of 44 C (111 F) begins to produce burns. But is dependent begins to produce burns. But is dependent on exposure time.on exposure time.

Temperature >44C and < 51C (124F) the Temperature >44C and < 51C (124F) the rate of epidermal necrosis doubles with rate of epidermal necrosis doubles with each degree of temperature increase.each degree of temperature increase.

At > 70 C (185F) or greater, exposure time At > 70 C (185F) or greater, exposure time required to cause transepidermal necrosis required to cause transepidermal necrosis is less than 1 second.is less than 1 second.

Normal process of water evaporation is Normal process of water evaporation is accelerated 5 to 15 time to that of normal accelerated 5 to 15 time to that of normal skin.skin.

Pathophysiology of BurnsPathophysiology of Burns(Local response)(Local response)

Based on Jackson’s Based on Jackson’s thermal wound theorythermal wound theory

Zone of hyperemiaZone of hyperemia– Increased blood flow due Increased blood flow due

to normal inflammatory to normal inflammatory responseresponse

Zone of stasisZone of stasis– Potentially viable tissuePotentially viable tissue– Cells are ischemic due to Cells are ischemic due to

clotting and clotting and vasoconstrictionvasoconstriction

Zone of coagulationZone of coagulation– Coagulation necrosis has Coagulation necrosis has

occurredoccurred– Tissue is non viableTissue is non viable

Pathophysiology of BurnsPathophysiology of Burns(Systemic response)(Systemic response)

Hypovolemic shock/”Burn shock”Hypovolemic shock/”Burn shock”– Response proportional to extent of body Response proportional to extent of body

surface injurysurface injury Pulmonary responsePulmonary response Gastrointestinal responseGastrointestinal response Musculoskeletal responseMusculoskeletal response Neuroendocrine responseNeuroendocrine response Metabolic responseMetabolic response Immune responseImmune response Emotional responseEmotional response

Burn injuriesBurn injuries(Primary Survey)(Primary Survey)

Recall that burn patients are first and Recall that burn patients are first and foremost trauma patientsforemost trauma patients

AirwayAirway BreathingBreathing CirculationCirculation DisabilityDisability ExposureExposure

AirwayAirway

Airway controlAirway control– Chin liftChin lift– Jaw thrustJaw thrust– Insert oral Insert oral

pharyngeal airwaypharyngeal airway– Assess need for ET Assess need for ET

intubationintubation Maintain in-line Maintain in-line

cervical cervical immobilization in immobilization in patients at riskpatients at risk

BreathingBreathing

Listen: verify breath soundsListen: verify breath sounds Assess rate and depth of respirationsAssess rate and depth of respirations Administer high flow O2Administer high flow O2 Monitor chest wall excursion in Monitor chest wall excursion in

presence of full thickness torso burnspresence of full thickness torso burns

Inhalational injuryInhalational injury

Present in 10 – 20 % of burn patientsPresent in 10 – 20 % of burn patients Identified in 60 – 70 % of patients Identified in 60 – 70 % of patients

who die in burn centerswho die in burn centers

Airway assessment and Airway assessment and managementmanagement

Humidified 100% O2 by maskHumidified 100% O2 by mask Endotracheal intubation indicated ifEndotracheal intubation indicated if

– Airway obstruction imminent as signaled Airway obstruction imminent as signaled by progressive hoarseness and/or stridorby progressive hoarseness and/or stridor

– LOC is such that airway protective LOC is such that airway protective reflexes are imparedreflexes are impared

Warning signs/cluesWarning signs/clues

Facial burns, singed nasal hairsFacial burns, singed nasal hairs Carbonaceous sputumCarbonaceous sputum Tachypnea, intercostal retractionsTachypnea, intercostal retractions HoarsnessHoarsness Agitation (hypoxia)Agitation (hypoxia) Rales, rhonchi, diminished breath Rales, rhonchi, diminished breath

soundssounds Inability to swallowInability to swallow Naso or oro-pharynx erythemaNaso or oro-pharynx erythema

CirculationCirculation

Monitor BP, pulse rate, skin colorMonitor BP, pulse rate, skin color Establish IV accessEstablish IV access

– If possible, place iv in non-burned skin, If possible, place iv in non-burned skin, but may place it in burned skin if but may place it in burned skin if needed.needed.

– How would you secure IV in burned How would you secure IV in burned tissue?tissue?

Assess circulatory status of Assess circulatory status of circumferentially burned extremitiescircumferentially burned extremities

Disability, Neurologic Disability, Neurologic DeficitsDeficits

Typically alert and oriented. If not, Typically alert and oriented. If not, why not?why not?

Remember AVPU?Remember AVPU?– A-AlertA-Alert– V-Responds to verbal stimuliV-Responds to verbal stimuli– P-Responds to painful stimuliP-Responds to painful stimuli– U-UnresponsiveU-Unresponsive

Disability, Neurologic Disability, Neurologic DeficitsDeficits

Please remember before you Please remember before you intubate, if possible, to get any intubate, if possible, to get any pertinent historypertinent history– AMPLE historyAMPLE history– A – AllergiesA – Allergies– M – MedicationsM – Medications– P – Previous medical/surgical historyP – Previous medical/surgical history– L – Last meal (time)L – Last meal (time)– E – Events/environment surrounding the E – Events/environment surrounding the

injury; ie. Exactly what happenedinjury; ie. Exactly what happened

Exposure/Environmental Exposure/Environmental controlcontrol

First must remove patient to a safe First must remove patient to a safe areaarea

Stop the burning processStop the burning process– Exstinguish fire – cool smoldering areasExstinguish fire – cool smoldering areas– Remove ALL clothing and ALL jewelryRemove ALL clothing and ALL jewelry– Cut around areas where clothing is stuck Cut around areas where clothing is stuck

to the skinto the skin– Cool adherent substances (Tar, Plastic)Cool adherent substances (Tar, Plastic)

Exposure/Environmental Exposure/Environmental controlcontrol

Once patient in safe areaOnce patient in safe area Maintain patient’s temperatureMaintain patient’s temperature

– Warm room or rigWarm room or rig– Keep patient covered; dry sheets, Keep patient covered; dry sheets,

blanketsblankets– Warm IV fluidsWarm IV fluids

Circumstances of Circumstances of InjuryInjury

Circumstances of Injury: Circumstances of Injury: FlameFlame

How did it occur?How did it occur?– Inside or outside?Inside or outside?– Clothing ignition?Clothing ignition?– Time to extinguish flame?Time to extinguish flame?– Extinguished how?Extinguished how?– Gasoline or other fuel involved?Gasoline or other fuel involved?– Explosion? Patient thrown?Explosion? Patient thrown?– Are purported circumstances of injury Are purported circumstances of injury

consistent with burn characteristics?consistent with burn characteristics?


Structure fire?Structure fire? Smoke filled space?Smoke filled space? Others injured or killed in event?Others injured or killed in event? Was there LOC at the scene?Was there LOC at the scene? How did the patient escapeHow did the patient escape

– Did the patient jump? How far was the Did the patient jump? How far was the drop?drop?

– Through glass?Through glass?


Automobile crash?Automobile crash? How badly was the car damaged?How badly was the car damaged? Other injuries?Other injuries? Did they hit anybody? Check around, Did they hit anybody? Check around,

under the vehicle.under the vehicle. Car fire?Car fire?

Circumstances of Injury: Circumstances of Injury: ScaldScald

What is the history of the injury?What is the history of the injury?– What was the liquid?What was the liquid?– What was the volume of liquid involved?What was the volume of liquid involved?– What was the temperature of the liquid? What was the temperature of the liquid?

If tap water, what was the heater temperature If tap water, what was the heater temperature setting?setting?

If heated by other source, was the liquid boilingIf heated by other source, was the liquid boiling

– Was the patient wearing clothing?Was the patient wearing clothing?– How quickly was it removed?How quickly was it removed?– Was the burned area cooled?Was the burned area cooled?– Was other first aid administered?Was other first aid administered?

Circumstances of Injury: Circumstances of Injury: ScaldScald

Is abuse or neglect Is abuse or neglect suspected?suspected?– How quickly was How quickly was

care sought?care sought?– Where did the burn Where did the burn

occur?occur?– Who was with the Who was with the

patient when the patient when the injury occurred?injury occurred?

– Does the story fit Does the story fit the injury?the injury?

Circumstances of Circumstances of Injury:ChemicalInjury:Chemical

Circumstances of Circumstances of Injury:ChemicalInjury:Chemical

What was the agent?What was the agent? Is it still around? Vapor?, Liquid?, Is it still around? Vapor?, Liquid?,

Solid?Solid? How did the exposure occur?How did the exposure occur? What was the duration of contact?What was the duration of contact? What decontamination occurred?What decontamination occurred? Was there an explosion? Was the Was there an explosion? Was the

patient thrown?patient thrown? What is the toxicity of the agent?What is the toxicity of the agent?

Circumstances of Circumstances of Injury:ElectricalInjury:Electrical

What kind of current was involved?What kind of current was involved? What was the duration of contact?What was the duration of contact? Was the patient thrown or did the Was the patient thrown or did the

patient fall?patient fall? What was the estimated voltage?What was the estimated voltage? Was there LOC?Was there LOC? Was CPR administered?Was CPR administered?

Circumstances of Circumstances of Injury:ElectricalInjury:Electrical

The great pretenderThe great pretender– Small surface injuries may be associated Small surface injuries may be associated

with severe internal injurieswith severe internal injuries– Causes about 1000 deaths/yr.Causes about 1000 deaths/yr.

First contactFirst contact

After patient in safe area…After patient in safe area… Complete head to toe examComplete head to toe exam Pre-existing medical conditions? Pre-existing medical conditions?

Tetnus status? Other injuries?Tetnus status? Other injuries?

Determine Burn SeverityDetermine Burn Severity

You must assess % of body surface area You must assess % of body surface area (BSA) involved(BSA) involved

Depth of injury (1Depth of injury (1stst, 2, 2ndnd, or 3, or 3rdrd degree) degree)– Realize that this is difficult to do as burns Realize that this is difficult to do as burns

may “mature” over time AND getting an may “mature” over time AND getting an exact percentage is usually not possibleexact percentage is usually not possible

Age of patientAge of patient Associated / pre-existing disease or Associated / pre-existing disease or

illnessillness Burns to hands, face, genitalia.Burns to hands, face, genitalia.

Extent of BurnExtent of Burn

Initial estimate of 2Initial estimate of 2ndnd and 3and 3rdrd degree burns: degree burns: “rule of nines”“rule of nines”– Adult areas = 9% BSA Adult areas = 9% BSA

or multiplesor multiples– Not accurate for Not accurate for

infants/children due to infants/children due to larger BSA of head and larger BSA of head and smaller BSA of legs.smaller BSA of legs.

To estimate scattered To estimate scattered burns, palm of hands burns, palm of hands and fingers of patient and fingers of patient = 1% BSA= 1% BSA

Burn DepthBurn Depth

Very young and very old patients Very young and very old patients have thinner skinhave thinner skin

Therefore, contact time at similar Therefore, contact time at similar temperatures will be worse for them.temperatures will be worse for them.

Pre-hospital management Pre-hospital management principlesprinciples

Stop the burning processStop the burning process Universal precautionsUniversal precautions Initiate fluid resusucitation per the Initiate fluid resusucitation per the

consensus protocol:consensus protocol:– 2 - 4 ml % BSA burn2 - 4 ml % BSA burn– ½ in 1½ in 1stst 8 hrs 8 hrs– ½ over next 16 hrs½ over next 16 hrs– *this is for adults only, pediatric patients *this is for adults only, pediatric patients

require consensus formula + D5LR require consensus formula + D5LR maintenence fluidsmaintenence fluids

Pre-hospital management Pre-hospital management principlesprinciples

Vital signsVital signs

Assess extremity perfusionAssess extremity perfusion– * remove all rings, watches, other * remove all rings, watches, other

jewelryjewelry– *Elevation of burned areas if possible*Elevation of burned areas if possible

Ventilation statusVentilation status

Pain relief/managementPain relief/management

Initial Burn Wound CareInitial Burn Wound Care

Thermal burnsThermal burns– Cover with clean, DRY clothCover with clean, DRY cloth– NO ice or cold water soaksNO ice or cold water soaks


Electrical InjuryElectrical Injury– Be aware of both cutaneous an internal Be aware of both cutaneous an internal

injuryinjury Entrance and exit points versus contact Entrance and exit points versus contact

pointspoints Arcing wounds vs electrical flash woundsArcing wounds vs electrical flash wounds

– Consider electrical current cardiac Consider electrical current cardiac effectseffects


Chemical burnsChemical burns– Scene control Scene control – Brush powders from skin and clothesBrush powders from skin and clothes

Watch shoes and socksWatch shoes and socks

– Remove contaminated clothingRemove contaminated clothing– Flush with COPIUS amounts of waterFlush with COPIUS amounts of water– Eye irrigation if involvedEye irrigation if involved– Exposure protection for yourselves and Exposure protection for yourselves and

anyone involved with patient careanyone involved with patient care

Burn center referral criteriaBurn center referral criteria

The ABA identifies the following as The ABA identifies the following as injuries requiring a Burn Center injuries requiring a Burn Center referral:referral:– 22ndnd degree burns > 10% TBSA degree burns > 10% TBSA– Burns to face, hands, feet, genitalia, Burns to face, hands, feet, genitalia,

perineum, major Jointsperineum, major Joints– 33rdrd degree burns degree burns– Electric injury (lightning included)Electric injury (lightning included)– Chemical burnsChemical burns

Burn center referral criteriaBurn center referral criteria

Inhalational injuriesInhalational injuries Burns accompanied by pre – existing Burns accompanied by pre – existing

medical conditionsmedical conditions Burns accompanied by trauma, where Burns accompanied by trauma, where

burn injury poses greatest risk of burn injury poses greatest risk of morbidity or mortalitymorbidity or mortality

Burns to children in hospitals without Burns to children in hospitals without pediatric servicespediatric services

Patients with special social, emotional or Patients with special social, emotional or rehabilitative needsrehabilitative needs

SummarySummary

Be able to assess injuriesBe able to assess injuries Be able to develop priority – based Be able to develop priority – based

plan of careplan of care Base care plan on type, extent, Base care plan on type, extent,

degree of burndegree of burn Consult with a burn center physicianConsult with a burn center physician Decide upon local treatment and Decide upon local treatment and

transport with burn center physiciantransport with burn center physician

Feel that burn…in your Feel that burn…in your coloncolon

Documents

Burns Burns. Burns John van der Steeg MD Objectives Incidence and patterns of burn injury Incidence and patterns of burn injury Pathophysiology of local