Burns Burns. Objectives Incidence and patterns of burn injury Incidence and patterns of burn injury Pathophysiology of local and systemic responses to

BurnsBurns

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

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

Burns

34-8

Burn Types

• Thermal (exposure to heat)– Examples: flame, scald, flash

• Chemical– Examples: acids, alkalis

• Electrical (including lightning)

• Radiation

34-9

Burn Severity

• Depth• Extent• Location• Patient age• Conditions present

before the burn• Associated factors

34-10

Burn Depth

• Superficial (first-degree) burn

• Partial-thickness (second-degree) burn

• Full-thickness (third-degree) burn

34-11

Depth of burn

Partial thickness Partial thickness burn =burn =

involves epidermisinvolves epidermis

Deep partial Deep partial thickness =thickness =

involves dermisinvolves dermis

Full thickness =Full thickness =

involves all of skininvolves all of skin

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.

Superficial (First-Degree) Burn

• Involves only epidermis

• Minor tissue damage

• Skin red, tender, very painful

– No blistering

• Does not usually require medical care

• Heals in ~2 to 5 days

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Superficial (First-Degree) Burn

34-15

Partial thickness burns

Sunburn is a very superficial burn.Sunburn is a very superficial burn. Expect blistering and peeling in a few days.Expect blistering and peeling in a few days. Maintain hydration orally.Maintain hydration orally. Heals in 3-6 days- generally no scaring Heals in 3-6 days- generally no scaring Topical creams provide relief. Topical creams provide relief. No need for antibioticsNo need for antibiotics

Partial-Thickness (Second-Degree) Burn

• Extends through epidermis into dermis

• Intense pain

• Some swelling

• Blistering may be present

• Skin pink, red, or mottled

• Heal in ~5 to 35 days

34-17


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

Partial-Thickness (Second-Degree) Burn

34-19

Deeper partial thickness

Blisters are typical of partial thickness burns.Blisters are typical of partial thickness burns. Don’t be in a hurry to break the blisters.Don’t be in a hurry to break the blisters. Heals in 14-21 daysHeals in 14-21 days Blisters provide biologic dressing and comfort.Blisters provide biologic dressing and comfort. Once blisters break, red raw surface will be very painful.Once blisters break, red raw surface will be very painful.

Full-Thickness (Third-Degree) Burn

• Destroys epidermis, dermis

• Skin color varies

• Looks dry, waxy, or leathery

• Numb – nerve endings destroyed

• Rapid fluid loss

34-21


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.

Full-Thickness (Third-Degree) Burn

34-23

Deeper partial thickness

Blisters are typical of partial thickness burns.Blisters are typical of partial thickness burns. Don’t be in a hurry to break the blisters.Don’t be in a hurry to break the blisters. Heals in 14-21 daysHeals in 14-21 days Blisters provide biologic dressing and comfort.Blisters provide biologic dressing and comfort. Once blisters break, red raw surface will be very painful.Once blisters break, red raw surface will be very painful.

Mixed partial and full thickness

Central yellow area might be full thickness.Central yellow area might be full thickness. Outer edges are probably partial thickness.Outer edges are probably partial thickness. Initial management is the same.Initial management is the same. Later will need skin grafts for the full thickness areas.Later will need skin grafts for the full thickness areas.

Zones of Burn Wounds

Zone of CoagulationZone of Coagulation devitalized, necrotic, white, no devitalized, necrotic, white, no

circulationcirculation Zone of Stasis ‘circulation sluggish’Zone of Stasis ‘circulation sluggish’

may covert to full thickness, mottled may covert to full thickness, mottled redred

Zone of HyperemiaZone of Hyperemia outer rim, good blood flow, redouter rim, good blood flow, red

Wound Wound excision until excision until fine punctate fine punctate

bleeding bleeding occursoccurs

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

Extent of BurnKey Points

• Only partial-thickness and full-thickness burns are included when calculating extent of a burn

• Extent of the burned area is important to determine– The depth of the burn must also be considered, although

superficial burns are not included in the calculation of the extent of a burn

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Extent of BurnRule of Nines

• “Rule of Nines”– Guide used to estimate body surface area

burned– Divides adult body into 9%, or multiples of

9%, sections– Modified for children and infants

34-32


Body Area Adult Child Infant

Head and neck 9% 18% 18%

Front of trunk 18% 18% 18%

Back of trunk 18% 18% 18%

Each arm (shoulder to fingertips)

9% 9% 9%

Each leg (groin to toe) 18% 13.5% 13.5%

Genitals 1% 1% 1%

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34-34

Extent of BurnRule of Palms

• “Rule of Palms” can be used for:– Small or irregularly shaped burns– Burns scattered over the body

• Palm of patient’s hand equals 1% of patient’s body surface area

34-35

Burns Best Treated in a Burn Center

• Second-degree burns involving over 10% total body surface area (TBSA) in adults or 5% TBSA in children

• Chemical burns• All burns involving hands, face, eyes, ears, feet, or

genitals• Circumferential burns of the torso or extremities• Any third-degree burn in a child• All inhalation injuries• Electrical burns, including lightning injury• All burns complicated by fractures or other trauma• All burns in high-risk patients including older adults, the

very young, and those with preexisting conditions such as diabetes, asthma, and epilepsy

34-36

Care of small burns

What can YOU do?

Care for Thermal Burns

• If patient still in area of heat source, move to safe area

• If clothing is in flames – stop, drop, and roll

• Remove smoldering clothing and jewelry– Cut around areas where clothing is

stuck to skin

34-38

Primary Survey

• Stabilize cervical spine if needed

• Was the patient in a confined space and exposed to smoke, flames, or steam?– How long was he exposed?– Did he lose consciousness?– Were hazardous chemicals involved?

– Be alert for potential airway problems

34-39

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

CirculationCirculation AirwayAirway BreathingBreathing 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

Inhalation Injury

• Facial burns• Soot in the nose or mouth• Singed facial or nasal hair• Swelling of lips or inside

mouth• Coughing• Inability to swallow

secretions• Hoarse voice

34-44

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?

Chemical Burns

• Degree of injury is based on:– Mechanism of action of the chemical– Strength of the chemical– Concentration and amount of the chemical– How long the patient was in contact with the

chemical– Body part in contact with the chemical– Extent of tissue penetration

34-60

Care for Chemical Burns

• Scene size-up– Gloves, eye protection, other PPE as

necessary– Additional resources may be needed

before you can safely enter the area

34-61


• General impression / primary survey– Manage airway and breathing– Stabilize cervical spine if needed– Remove patient’s jewelry– Remove clothing, including shoes and

socks

34-62


• Stop the burning process– Brush off dry chemicals

• Brush chemical away from the patient

– Flush the burn with large amounts of room temperature water

• Use low pressure• Flush for at least 20 minutes

• Treat other injuries, if present

34-63

EyeChemical Burn

• Most urgent eye injury

• Damage depends on:– Type and concentration of the chemical– Length of exposure– Elapsed time until treatment

34-64

Early Signs of a Chemical Burn

• Pain

• Redness

• Irritation

• Tearing

• Inability to keep eye open

• A sensation of “something in my eye”

• Swelling of the eyelids

• Blurred vision

34-65

Chemical Burn to the Eye

• Emergency care

– Ask patient to remove contact lenses, if present

– Immediately flush the eye with water or normal saline

– Continue flushing for at least 20 minutes

– Flush away from the unaffected eye

34-66

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.

Electrical Burns

• Severity of an electrical injury is related to:– Amperage (current flow)– Voltage (current force)– Type of current (AC/DC)– Current pathway through the body– Resistance of tissues to current– Duration of contact

34-69

Electrical Burns

• Skin normally resists the flow of electric current into the body– Electricity entering the body is converted

to heat– Current follows paths of least resistance

• Blood vessels, nerves, muscles

34-70

Care for Electrical Burns

• Make sure the power is off!• Contact additional resources if needed

before entering the area

34-71


• Manage ABCs

• Stabilize cervical spine if needed

• Watch closely for respiratory and cardiac arrest– Make sure an AED

is available

34-72


• Treat other injuries if present• Look for entrance and exit wounds

34-73

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 morbidity burn injury poses greatest risk of morbidity or mortalityor 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

Physical Examination

• Check pulses in all extremities– Circumferential burn can act as a

tourniquet

• After all immediate life-threats have been managed, care for the burn itself

34-86

Physical Examination

• Quickly determine burn severity• Vital signs• Medical history• Questions related to the burn:

– How long ago did the burn occur?– How did it occur?– What was done to treat the burn before

you arrived?

34-87

Treat the Burn

• Cool the burn with cold water

• Cover burned area with a dry dressing or sheet

• Keep patient warm

– Cover with clean, dry sheets

• Remove all jewelry

• Look for other injuries

– Treat and immobilize possible fractures

– Treat soft-tissue injuries if present

– Treat shock if present

• Keep burned extremities elevated above the heart

• Transport to closest appropriate facility

34-88

Treat the Burn

• Do not apply ice, butter, oils, sprays, lotions, or ointments to a burn

• If a blister has formed, do not break it

– Loosely cover the blister with a sterile dressing

• Do not place ice or wet sheets on a burn

• Do not transport a burn patient on wet sheets, wet towels, or wet clothing

34-89

Infant / Child Considerations

• Larger BSA than adults in relation to total body size– Greater fluid and heat loss

• More likely to develop shock or airway problems than adults

• Consider possibility of abuse when treating a burned child

• Report all suspected cases of abuse to appropriate authorities

34-90

Care of small burns

Clean entire limb with Clean entire limb with

soap and water (also under nails).soap and water (also under nails). Apply antibiotic cream Apply antibiotic cream

(no PO or IV antibiotic).(no PO or IV antibiotic). Dress limb in position of function, Dress limb in position of function,

and elevate it.and elevate it. No hurry to remove blistersNo hurry to remove blisters unless infection occurs. unless infection occurs. Give pain meds as needed (PO, IM, or IV) Give pain meds as needed (PO, IM, or IV) Rinse daily in clean water; in shower is very practical.Rinse daily in clean water; in shower is very practical. GentlyGently wipe off with clean gauze. wipe off with clean gauze.

Blisters

In the pre-hospital setting, there is no In the pre-hospital setting, there is no hurry to remove blisters. hurry to remove blisters.

Leaving the blister intact initially is less Leaving the blister intact initially is less painful and requires fewer dressing painful and requires fewer dressing changes. changes.

The blister will either break on its own, The blister will either break on its own, or the fluid will be resorbed. or the fluid will be resorbed.

Blisters break on their own

Upper arm burn day 1 day 2Upper arm burn day 1 day 2

Burn “looks worse” the next day because of blisters breaking and oozing

Upper arm burn

Blisters show probable partial thickness burn.Blisters show probable partial thickness burn. Area without blister might be deeper partial Area without blister might be deeper partial

thickness.thickness.

121

Debride blister using simple instruments

Medic debriding blister

After debridement

Before and after debridement

Removing the blister leaves a weeping, very Removing the blister leaves a weeping, very tender wound, that requires much care.tender wound, that requires much care.

Silver sulfadiazene

Arm burn 4 days

Arm burn 7 days – note the exudate

Foot burn debridement

Before debriding and applying cream, clean entire foot(including toes and nails).

Silver- impregnated dressings (Silverlon)

Apply wet silver dressing Apply wet silver dressing

directly on the burn.directly on the burn. Creams or dressings Creams or dressings

under the silver dressing under the silver dressing

impede the antimicrobial action.impede the antimicrobial action. Keep it moist!Keep it moist! Remove it, rinse it out, replace it on the Remove it, rinse it out, replace it on the

burn.burn.

Steps in using silver-impregnated dressings

Clean the burn and surrounding area. Clean the burn and surrounding area. Soak silver-impregnated dressing and gauze in Soak silver-impregnated dressing and gauze in STERILE WATER or BOTTLED DRINKING STERILE WATER or BOTTLED DRINKING

WATER WATER Apply silver-impregnated dressing Apply silver-impregnated dressing

(over-lapping edges are best). (over-lapping edges are best). Wrap with the moist gauze. Wrap with the moist gauze. Secure with mesh, gauze, or tape.Secure with mesh, gauze, or tape. Keep it moist with WATER, every 12h or so Keep it moist with WATER, every 12h or so

More frequent in hot arid environmentsMore frequent in hot arid environments

picsSoak silver dressings and gauze in WATER (not saline).

Apply thesilver dressing.

Wrap with moist gauze.Secure with mesh, gauze, or tape.

First few days Moisten dressing with WATER every 12h or so.Moisten dressing with WATER every 12h or so. Remove outer gauze and silver dressing every Remove outer gauze and silver dressing every

day.day.Inspect the burn. Inspect the burn. Rinse exudate off burn.Rinse exudate off burn.

Rinse exudate off silver dressing with WATER.Rinse exudate off silver dressing with WATER. Return same silver dressing to the burn.Return same silver dressing to the burn. Apply new outer gauze moistened with Apply new outer gauze moistened with

WATER.WATER.

pics Moisten with WATER q12h or so.

Moisten wellto remove it each day.Rinse it out, and put it back on the burn.

After several days

Replace silver dressing Replace silver dressing every 2 - 5 days every 2 - 5 days depending on amount of exudate, depending on amount of exudate,

cellular debriscellular debris First wet the silver dressing before removing First wet the silver dressing before removing

it.it. Don’t pull on it if it’s stuck – moisten it more.Don’t pull on it if it’s stuck – moisten it more. Apply new moist silver dressing and gauze.Apply new moist silver dressing and gauze.

QUESTIONS ABOUT SMALL BURNS?

SUMMARYSUMMARY

Describe the differences between partial and Describe the differences between partial and full-thickness burns.full-thickness burns.

Describe how to estimate the size of a burn.Describe how to estimate the size of a burn. Describe initial care of small burns.Describe initial care of small burns. Describe follow-up and post-burn care.Describe follow-up and post-burn care.

NEXT TOPIC - BURNS OF SPECIAL AREASNEXT TOPIC - BURNS OF SPECIAL AREAS

Burns of special areasof the body

Face Face MouthMouth NeckNeck Hands and feetHands and feet GenitaliaGenitalia

Face Be Be VERYVERY concerned for the airway!! concerned for the airway!! Eyelids, lips and ears often swell Eyelids, lips and ears often swell

alarmingly.alarmingly. In fact, they look even worse the next day.In fact, they look even worse the next day. But they will start to improve daily after But they will start to improve daily after

that.that. Cleanse eyes with warm water or saline. Cleanse eyes with warm water or saline. Apply antibiotic ointment or liquid tears Apply antibiotic ointment or liquid tears

until lids are no longer swollen shut. until lids are no longer swollen shut. Bacitracin cream/ointment will serveBacitracin cream/ointment will serve

Hands and feet

This is rather deep This is rather deep and might require and might require grafting. grafting.

But initial But initial management is basic.management is basic.

Dressings should not impede Dressings should not impede circulation.circulation.

Leave tips of fingers exposed.Leave tips of fingers exposed.

Keep limb elevated.Keep limb elevated.

Hands and feet Fingers might develop Fingers might develop

contractures if active contractures if active measures are not taken measures are not taken to prevent them.to prevent them.

Infant / Child Considerations

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Older Adult Considerations

• Mechanisms and severity of burn injury related to:

– Living alone

– Wearing loose-fitting clothing while cooking

– Falling asleep while smoking

– Declining vision, hearing, and sense of smell

– Slowed reaction time

– Problems with balance and/or memory

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Escharotomy

Eschar = burned skinEschar = burned skin Escharotomy = cut burned skin to Escharotomy = cut burned skin to

relieve underlying pressurerelieve underlying pressure Similar to bivalving a tight cast.Similar to bivalving a tight cast. Cut along inside and outside of Cut along inside and outside of

limb from good skin to good skinlimb from good skin to good skin Knife can be used, or cautery.Knife can be used, or cautery. Use local or no anesthesia. Use local or no anesthesia. (Full-thickness burn should have (Full-thickness burn should have

no sensation, but underlying no sensation, but underlying tissues do!)tissues do!)

Escharotomy of forearm

Incise along medial Incise along medial and/or lateral surfaces.and/or lateral surfaces.

Avoid bony Avoid bony prominences.prominences.

Avoid tendons, nerves, Avoid tendons, nerves, major vessels.major vessels.

Escharotomy Patient had escharotomy ofPatient had escharotomy of

both legs.both legs. Incisions will heal.Incisions will heal. They will not be closed by They will not be closed by

DPC.DPC. These large burns are often These large burns are often

treated by the “open” treated by the “open” technique,technique,

that is, without dressings. that is, without dressings.

Electrical burn Outer skin mightOuter skin might not appear too bad.not appear too bad.

But heat was conducted But heat was conducted along the bone.along the bone.

Causes the most damage.Causes the most damage.

Burns from inside out.Burns from inside out.

Usually requires fasciotomyUsually requires fasciotomy

Fasciotomy

Fascia = thick white covering of muscles.Fascia = thick white covering of muscles. Fasciotomy = fascia is incised (and often overlying skin)Fasciotomy = fascia is incised (and often overlying skin) Skin and fascia split open due to underlying swelling.Skin and fascia split open due to underlying swelling. Blood flow to distal limb is improved.Blood flow to distal limb is improved. Muscle can be inspected for viability.Muscle can be inspected for viability.

Dressing and Bandaging

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• Dressing– Absorbent material placed directly over a

wound

• Bandage– Used to secure a dressing in place

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• Functions of dressing and bandaging wounds:– Help stop bleeding– Absorb blood and other drainage from the

wound– Protect wound from further injury– Reduce contamination and risk of infection

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Dressings

• A dressing should be:

– Lint free

– Large enough to cover the wound

• Should extend beyond wound edges

– Sterile whenever possible

– Applied directly over the wound

• Do not slide it in place

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Types of Dressings

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Sterile Gauze Pads

• Loosely woven material

• Classified by size in inches– 2 x 2– 4 x 4

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Trauma Dressing

• Thick dressing• Various sizes• Two layers of gauze

with absorbent cotton in center

• Uses– Large wounds– Pad injured limb

inside a splint

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Occlusive Dressing

• Made of nonporous material• Used to cover open wound and make

airtight seal– Chest wound– Neck wound

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Nonadherent Pads

• Gauze pads with special coating• Used to cover leaking open wound but not

stick to it

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Eye Pads

• Uses:– Cover eyes after minor eye injury– Cover small wound, such as a puncture

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Bandages

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Bandages

• Applied to keep a dressing in place

• Does not have to be sterile

• Before applying to an extremity:

– Remove patient’s jewelry

– Check pulse distal to the wound

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Roller Gauze (Kling)

• Secures dressing in place– 1-inch roll for fingers– 2-inch roll for wrists, hands, feet– 3-inch roll for elbows, upper arms– 4- to 6-inch roll for ankles, knees, legs

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Roller Bandage

• Soft, slightly elastic material• Available in various widths

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Elastic Bandage

• Do not use to secure a dressing in place• May act as a tourniquet if injured area swells

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Triangular Bandage

• Large piece of muslin • When folded, can be used as a

bandage or sling

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Self-Adherent Wrap

• Elastic wrap coated with self-adhering material

• Often used as a pressure bandage

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Pressure Bandage

• Applied over a wound site to control bleeding• Cover the wound with a dressing • Apply direct pressure until the bleeding is

controlled• Secure the dressing in place with a bandage• Assess the pulse distal to a bandage

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Applying a Roller Bandage

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Head or Ear Bandage

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Upper Arm Bandage

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Elbow Bandage

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Wrist or Forearm Bandage

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Knee Bandage

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Foot or Ankle Bandage

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Documents

Burns Burns. Objectives Incidence and patterns of burn injury Incidence and patterns of burn injury Pathophysiology of local and systemic responses to