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92 Cards in this Set

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  • Back
What are burns?
Diffuse soft tissue injuries created by destructive energy transfer via radiation, thermal or electrical energy.
What factors affect the severity of a burn?
The severity of a burn correlates directly with temperature, concentration (amount of heat energy possessed by the object or substance) and the duration of exposure.
What is a thermal burn?
Caused by fire or other sources of heat energy such as chemical, electicity and radiation.
What are flame burns?
Thermal burns caused by open flame.

Can often be a very deep burn.

Can often be associated with inhalation injuries.
What are scold burns?
Hot liquids produce scald burns.

Most often seen with children and handicapped adults.

Often cover large areas as liquids can spread quickly.

Can soak into clothing and continue to burn.

Liquids such as oil and greese can stick to the skin causing a deep scald.
What are contact burns?
Contact burns occur when a hot surface or heat source is touched.

Usually not deep unless the patient was prevented from withdrawing away such as during a stroke.

Burns in strange places or patterns of burns in children and older adults should raise suspicion of abuse.
What are steam burns?
Produce a topical scald. Can also cause airway burns.

May cause upper airway burns. Steam can cause significant injury to the lower airway because of the minute particles of hot water contained.
What is burn shock?
Occurs due to two types of injury.

Fluid loss accross damaged skin.

Volume shifts within the rest of the body.
What happens to the body with burn shock?
Capillaries become leaky and intravascular volume oozes out of circulation and into interstitial spaces.

The cells of normal tissue take in increased amounts of salt and water from the fluid around them.
When does burn shock set in?
During a 6-8 hour period.
What happens if an acutely burned patient is in shock in the prehospital stage?
Look for another injury as the cause of the shock.

People can fall through floors, jump from windows or be caught in collapse.
What are airway burns?
Inhalation burns that can cause rapid and serious airway compromise.

Heat can be an irritant and can cause coughing wheezing and swelling of the upper airway tissues.
What is lower airway damage associated with?
Inhalation of steam or other hot particulate matter.
What is upper airway damage associated with?
More often associated with the inhalation of superheated gases.
What treatment may be required?
Aggressive airway management may be necessary if swelling threatens the patient's airway.

Heat inhalation can also cause laryngospasm and bronchospasm in the lower airway.
What damage can smoke inhalation do?
Materials release toxic chemicals and cause tissue damage as a result of inhalation.

Patients can suffer from hypoxia due to the low O2 content of the environment.

Suffer thermal burns to the airway from the heat.
What is Carbon monoxide poisoning?
CO binds to receptor sites on hemoglobin 250 times more readily than oxygen. This displaces O2.

This means that it is relatively easy for small concentrations of CO to result in fatal saturation levels.
What is traditional wisdom with regards to CO?
Patients with CO poisoning will appear cherry red. In reality this skin is most often seen in patients that are already dead.
What are chemical burns?
Occur when the skin comes into contact with strong acids, bases or other such corrosives.
How long does the burn last?
The burn lasts as long as the substance remains in contact with the skin.
What determines damage?
The concentration of the chemical and the duration of the contact.
What should be done?
Most chemicals can be removed by washing with copious amounts of water from a shower sink or eyewash station.
What can happen at skin folds?
Chemicals can accumulate and remain in tissue folds.

Be very careful to wash at joints and fingers.
What if chemicals react with water?
Such chemicals are usually powders.

Brush off as much of the powder as possible before irrigating any chemical exposure.
What is different about the rule of the nines with chemical burns?
Estimate the area of the body involved but also be aware that the extent of the injury may be more severe.
How long to chemical burns take to effect?
Typically they react with the skin quickly. In some cases the injury may take time to develop as in a person who is exposed to cement. This reacts with sweat and the injury can be noticed hours later.
What influences a chemical burns severity?
The agent involved, concentration, volume and duration of contact
What are the three types of burns that can be caused by electricity?
Type 1, Type 2 and Type 3
What are Type 1 burns?
The most common type, these are contact burns. You can see the classic bulls eye lesion sometimes.

The contact burn in itself is not very serious but it may signal injury within the body.
What are Type 2 burns?
Flash burns caused by the arcing of current. These arcs can have temps of 3,000 to 20,000 degrees C and can produce significant charring.
What are type 3 burns?
Occurs when electricity ignites a persons clothing or surroundings.
What is the first thing to consider with electrical burns?
Scene safety. Ensure that the power has been shut off.
Why are electrical burns classified as critical burns?
Due to the high possibility of internal injury between the point of entry and exit. Electricity can flow across the chest injuring the cardiac conduction system.
What are non-burn injuries that can be caused by electricution?
Asphyxia - Can occur with prolonged contact inducing contractions of the respiratory muscles or the impulse to breath be knocked out in the brain.

Cardiac Arrest - Can occur from hypoxia or direct result of the shock.

Arrhythmias can occur even if the heart is not stopped.

Neurological Damage - seizures, delirium, confusion, coma

Kidney damage - breakdown of products from damaged muscle gets into circulation like with crush injuries.

Muscle spasms can cause fractures and dislocations.

Cervical spine injuries from falls from utility poles etc.
What do lightening injuries tend to resemble?
Blast injuries with damage to the tympanic membranes and air containing internal organs.

Muscle damage can occur and the release of myoglobin can jeopardize the kidneys.
What happens the the heart with a lightening strike?
It is a massive DC shock that depolarizes the entire heart.

The heart can resume beating spontaneously shortly after the shock or after two minutes of CPR.
What are the immediate threats to life following a lightning strike?
Airway obstruction, respiratory arrest and cardiac arrest.
What us acute radiation syndrome?
Causes hematological, central nervous system and gastrointestinal changes.
What is the significance of vomiting?
Patients rendered unconscious or vomit within 10 minute do not survive.

Patients who show vomiting within 1 hour have 30-80% survival rate.

Vomiting within 1-2 hours have 95-100% survival rate.
What are radiation contact burns?
Sustained when a patient handles a radioactive source. The injury could be anything from a sunburn to a chemical burn.
Why can burns fool paramedics?
Critically injured people are expected to act sick. Patients with burns can still be walking and this can mask the severity of an injury.
What is the primary concern with burns?
Make sure that the scene is safe.

Look for hazards, Electrical wires, placards, gas lines, collapse zones, gases, pooled fuels.
What is the first step to treating a burn patient?
Ensure that the fire is out and cool the burns.

Remove any clothing or articles than can retain heat.

Cool and cut off rings which can become tourniquets.

Try and determine the mechanism of injury. Did they jump or fall, were they removed from a collapse etc
What are you looking for in the initial assessment?
Assess how severe the injuries may be?

Serious burns can present with little or no pain. The patient may complain of feeling cold.

Recently burned patients may appear dazed or disconnected from events around them.
What do you need to focus on in the initial assessment?
Focus on the ABC's and show compassion for the patient regardless of their appearance.
What should you assume with combative patients.
Assume that the patient is hypoxic until proven otherwise.
What should unresponsive patients be assessed for?
The presence of other deadly injuries.
What are you looking for when ensuring an open airway?
Damage to the airway from the heat and flames that caused the external burn.

Laryngeal edema is rare but can develop with rapid speed especially in children and infants.
What are you looking for when assessing breathing?
Listen to lung sounds and pay attention to stridor a sound of impending upper airway compromise.
What can benefit patients with upper airway burns?
Humidified cool oxygen.
What about patients with preexisting lung disease?
They can have brochospasm after a minor exposure to smoke and may respond well to inhaled beta-2 agonists.
What are some points regarding circulation?
Unless the patient is hypotensive do not delay transport by making many attempts at vascular access.

Burn shock does not set in for a while so unless the transport time is long or the burn occurred some time ago it can wait till the ED.

Most serious burn patients need central venous access.

If the burn patient is in shock in the pre-hospital phase look for another cause for this shock.
What is the zone of coagulation?
The central area of the skin which suffers the most damage.
What is the zone of stasis?
The peripheral area which has decreased blood flow and inflammation.

This area can undergo necrosis within 24-48 hours after injury if perfusion is compromised by burn shock.
What is the zone of hyperemia?
The area least affected by the thermal injury. Cells can recover in 7-10 days.
What is a superficial burn?
Involves the epidermis only. The skin is red and when touched will blanch and return.

Pain will be experienced as nerve endings are exposed to air.
What is a partial thickness burn?
Involves the epidermis and varying degrees of the dermis.

Usually there are blisters or moisture and extreme pain. Hair follicles remain.

Superficial partial thickness burns will heal but may leave behind scar tissue or changed appearance.

Deep partial thickness burns can damage the hair follicles and sebaceous glands.
What is a full thickness burn?
Involves destruction of both layers of the skin, including the basement membrane of the dermis that produces new skin cells.

Skin is white, pale brown and leathery or charred. There is no cap refill.

There may be no pain in the full thickness section as the sensory nerves are destroyed.

Treatment will usually require skin grafting as the dermis has been destroyed.
How is the surface area of a burn calculated?
The rule of the nines and the rule of the hand.
How is the rule of the nines worked out for an adult?
Head = 9%
Chest and Abdomen = 18%
Back = 18%
Legs = 18% each
Arms 9% each
Genitals = 1%
Total = 100%
How is the rule of nines worked out for a child?
Head = 12%
Chest and Abdomen = 18%
Back = 18%
Legs = 16.5% each
Arms = 9%
Genitals = 1%
Total = 100%
How is the rule of nines worked out for an infant?
Head = 18%
Chest & Abdomen = 18%
Back = 18%
Legs = 13.5% each
Arms = 9% each
Genitals = 1%
Total = 100%
What can happen with circumferential burns?
Progressive edema beneath a circumferential burn can act as a tourniquet especially if the skin has become leathery and unyielding.

In the neck this could obstruct the airway. In the chest it may restrict respiration and in an extremity it may cut off the circulation and put the extremity in jeopardy.

The patient will need to be transported as soon as possible to definitive care in order to have a decompression cut made.
What is the 30% rule when dealing with radiation burns?
A burn of greater than 30% from radiation is often fatal. Keep this in mind when making transport decisions.
What is the immediate management for burn patients?
Stop the burning and cool the burns. Cool hot items such as jewelry.
What do you need to do after you cool the burns?
Cover the patient, need to keep them warm. They can quite easily become hypothermic if you are not careful.
What about other injuries?
Keep in mind the mechanism of injury. If the person is at high risk of spinal injury then they need to be treated as such.
What about medical conditions?
Burns can exacerbate underlying medical conditions such as COPD, asthma and cardiac conditions.
What about airway management?
If invasive airway management can be avoided it should be.

Try and get the patient to the hospital with the minimum of resources such as BVM and OPA.

If the airway is in imminent danger of closing then can use an advanced airway such as the king LT or the combitube
What about Fluid Resuscitation?
An IV line may be inserted in the pre-hospital setting to administer fluids and/or pain medications.
What type and when?
A large bore IV should be inserted as early as possible in any patient who has been severely burned.

Do not delay transport to do so.
How do you determine how much fluid the patient needs?
The parkland burn formula.
What is the parkland burn formula?
4ml x body weight (kg) x % of surface burned
What does this give you?
This gives you the amount of fluid that the patient must receive in the first 24 hours.

Half of the total needs to be given in the first 8 hours!
How are superficial burns managed?
Immerse the burned area in cool water or apply cold compresses to the burn.

Hands and feet can be soaked directly in cool water and towels soaked in cool water can be applied to the face or trunk.

No further treatment should be necessary in the pre-hospital setting.
How are partial thickness burns managed?
Cool the burned area with water or the application of wet dressings can diminish edema.

Burned extremities should be elevated to minimize edema formation.

Establish IV fluids
How are full thickness burns managed?
Dry dressings are used after the fire has been put out and cooled.

Establish IV access
How are chemical burns treated?
Speed is essential! Begin flushing the exposed area of the patients body immediately with copious quantities of water.

While flushing remove the patients clothing especially shoes and socks.

Take care not to contaminate yourself.
How long should flushing be for?
Preferable for 30 mins before moving the patient. For some strong alkalis uo to 1-2 hours of flushing.

Must look at the realities of flushing on scene against the benefits of transporting.
What should you do after flushing?
Limit hypothermia by keeping the patient covered and warm.
How are chemical burns of the eye treated?
Flush the eye with copious amounts of water.
What if their are contact lenses?
After flushing for a while stop and get the patient to remove their contacts and then continue flushing.
How are electrical burns managed?
Neutralize the hazard

Open the airway with a Jaw Thrust as may be cervical spine injury.

Start CPR if indicated

Attach the cardiac monitor even if not in arrest as arrhythmias need to be monitored.
How are lightning related injuries managed?
If the storm is still ongoing then move the patient to a safe place, preferably into the back of the ambulance. Use C-spine precautions.
What about patients in cardiac arrest?
Patients in arrest need aggressive and continuing CPR. The chances of success are good in this case.
What are the stages for managing treatment of lightning injuries?
=Make sure scene is safe
=Priority to patients who are not breathing
=Establish airway with C-spine protection
=Perform CPR as needed
=Administer supp O2
=Monitor the cardiac rhythm
=Insert large bore IV and run wide open to flush kidneys
=Cover surface burns with dry sterile dressings
=Splint fractures
=Immobilize the spine if the patient has fallen
What should be checked with children and Geriatrics who are burned?
Glucose levels. Children and Elderly patients have poor glycogen stores.
What do children require more of?
Need more fluid per kilogram than adults due to their increased body surface to weight ratio.
What patients should be transferred to a burns unit?
=Partial thickness burns of more than 10% of body surface area.

=Burns involving the face, hands, feet, genitalia, perineum or major joints.

=Full thickness burns in any age group

=Electrical burns inc lightening

=Chemical burns

=Inhalation burns

=Burns with complicating factors such as pre-existing medical conditions

=Burns with trauma in which the burn poses the greatest risk

=Burn injury requiring special social, emotional or long term rehab.
What are minor burns?
Superficial - less than 50%
Partial - less than 15%
Full Thickness - less than 2%
What are moderate burns?
Superficial - greater than 50%
Partial - less than 30%
Full - less than 10%
What are critical burns?
Partial - greater than 30%
Full - greater than 10%
Inhalation injury
Partial or full involving hands, feet, joints, face or genitalia.