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66 Cards in this Set

  • Front
  • Back
The Burn depth is determined by:
Length of exposure/duration of contact
Dermal thickness/Location of injury
Children and older adults have thinner skin and deeper burn at shorter duration of contact
Difficult to determine initially
Appearance may vary based on cause.
Burn Zones:
Zone of coagulation
Zone of stasis: effected by hypothermia, inadequate fluid resuscitation, and inadequate tissue perfusion
Zone of hyperemia (redness)
First degree Burn: Superficial-describe
Epidermis only
Pink to red
Heals in 3-5 days with no scarring
First degree burns are not included when calculating %TBSA
Put cool water on first degree…No ice!!
Treatment of First degree burns
Over the counter pain meds
Monitor for fever
Cool showers or baths
Aloe vera
Avoid re-exposure
Second degree: Partial thickness
Epidermis and part of dermis
Heal without surgical intervention
-capillary refill may be prolonged
Third Degree: Full Thickness
Epidermis, Dermis, subcutaneous tissue
Surgical intervention
No blanching/capillary refill
Charred, bright red, marbled, leathery, tan, waxy, or pearly white
Circumferential Full thickness burns
Peripheral pulses
Doppler, pulse oximetry
Symptoms of circulatory compromise
5 P’s: pain, pallor, pulselessness, progressive paresthesia, paralysis.
Management of Circumferential Burns
Elevate burned extremities
Remove constrictive garments and jewelry
Monitor closely
Escharotomy only in consultation with Burn center (escharotomy-cut through dead tissue. Lateral and medial cut, don’t go over a bony prominence because you may split a tendon). Pt must be medicated before escharotomy-versed/ativan
Outcome of Injury
Dependent on :
Total body surface area (TBSA)
depth of burn
Inhalation injury
Pre-existing medical history
Timeliness of treatment
Appropriateness of treatment
Adequate fluid resuscitation
Local reaction: Immediate
Capillary and cell wall destruction
-vasoconstriction, thrombosis, ischemia
Worse if hypothermic ***
Increased capillary permeability
Seepage of plasma proteins, fluids and electrolytes into interstitial tissues
Blister and edema formation
Systemic reaction
Immune suppression
-decreased circulating volume
Initial decreased cardiac output
Hypotension, hypoperfusion and hypovolemia
Tissue damage with local edema
Increased shunting
Increased O2 requirements
Decreased peristalsis and absorption
Low blood flow
Decreased Urinary output
Hemoglobin or myoglobin clogging
Low fluid volumes
Insert urinary catheter
Diuresis after 48-72 hours
Primary assessment Life and Limb threatening
-with C-spine protection
CIRCULATION, Cardiac Status, CPR
DISABILITY, Deformity, Neurological Deficit
EXPOSE, Examine, Environmental Control
-stop the burning process
Inhalation injury
Significant predictor of mortality
Three types:
Carbon monoxide
Upper airway
Lower airway
Carbon monoxide
Lower Levels
-headache, fatigue, flu-like symptoms, weakness, SOB, dizziness, nausea, blurred vision, may appear intoxicated
Higher Levels
-vomiting, confusion, heart palpitations
Progresses to
-seizures, coma, death
Signs of inhalation injury
-enclosed space fire
-chemicals (meth)
Burns of face or neck
Singed nasal or facial hair
Hoarsness, sore throat, cough, difficulty swallowing, carbonaceous sputum
Shortness of breath, dyspnea
Signs of hypoxia
-disoriented, restless, confused, agitated
Intubation guidelines
-transport time greater than 1 hour from time of injury to arrival at first hospital
C-Spine precautions
Consider intubation
-wheezing, stridor, dyspnea, respiratory distress
Sternal or abdominal retractions
Second or third degree burns of the face or neck
Circumferential burns of the chest or neck.
No Succinyl choline
-hyperkalemia in burns
Non depolarizing neuromuscular blockers
-Nasal vs. oral
Circulation, Cardiac Status
Circumferential burns
BP and Pulse
-Normal adult 110-120 bpm
Absence of distal pulses with circumferential burns not indicative of hypotension
-Hypotension-late sign of hypovolemia
Cardiac Monitor
Initiate fluid resuscitation
Initial Fluid Resuscitation
Two large bore IV’s
-Adults greater than 20%
Pediatrics greater than 15%
Site selection
-peripheral: unburned
-peripheral: burned
-Central lines
Femoral only
No cutdowns
Ideal Body temperature for burned person
101.5---So, the room temperature may be 110.
Don’t give Tylenol until 102. 5. Get blood culture at 103.
Neuro Assessment
Level of consciousness
Affected by hypoxia, carbon monoxide, head injury, pre-existing mental conditions, drugs, alcohol
Responsive to Verbal stimuli
Responsive to Painful stimuli
Exposure, Examine, Environment
Stop the Burning Process
Remove from heat source or danger with caution
Remove all clothing, diapers, jewelry, and metal
Cool the burn briefly
No ice
Cover with clean, dry covering
Maintain body temperature
Warm environment
Relatively larger body surface area
Larger head
Little insulation
Inability to shiver
Assume environmental temperature.
Why not cool and wet
Systemic hypothermia
Localized hypothermia
Goose-bumps and shivering
Painful rewarming
Get-typed blankets and dressings contraindicated
Secondary Assessment
Thorough head to toe
Log roll
Calculate percent of burn
Fluid resuscitation
Calculate based on % total body surface area and weight
Minor associated injuries
Changes in level of consciousness
Pain management
Anxiety Management
Labs, lines, tests
Constant monitoring and reassessment.
Percent of burn
Child: 9% =arm
16% = head

18% torso and back
4% for arm/ 4% back of arm
4 ½ % for head and 4 ½ % back of had
1% for neck and 1% back of neck
9% leg (x4-2 legs + back of legs)
Prehospital Fluids
Prehospital Fluids
• Transport time >than 1 hour from time of injury
• >20% TBSA
- fluid resuscitation
- pain management
• Inhalation injury
• Cardiac dysrhythmias
• High voltage electrical injuries
• Hypovolemia from associated trauma
• Based on age, not percent and weight - <5 years old: 150 ml LR per hour
- 5 - 15 years old: 250 ml LR per hour
- >15 years old: 500 ml LR per hour
Fluid Resuscitation
Fluid Resuscitation
• 4 cc LR x wt. kgs. x % TBSA burned - second and third degree only
- 1/2 in first eight hours from time of injury
- balance in next 16 hours
• Only an estimate!
• Treat patient response - bum vs trauma
• Example
- 70 kg person with 50% TBSA
- 4 ml x 70 x 50 = 14,000 (14lts in first 24 hours)
- 7,000 ml in first 8 hours = 875 per hour
- if 1 hour post-bum
• 7000 / 7 hours = 1000 mI / hour
Pediatric Fluids
Pediatric Fluids
• Resuscitation fluids -LR
- titrate to maintain urine Output
• Maintenance fluids -D5LR
- constant rate
- amount the child would need if healthy and NPO
Fluid Resuscitation - Special Needs
Fluid Resuscitation - Special Needs

• Patients who will require more fluids - high voltage electrical injuries
- inhalation injury
- delayed resuscitation
- associated trauma
- preexisting dehJdration
- alcohol use or abuse
- memlabs
Fluid Resuscitation Monitoring
Fluid Resuscitation Monitoring

• Urinary outputs

- most reliable indicator or adequacy or inadequacy of fluid resuscitation
- insert urinary cameter
- over 30 kgs: 30 - 50 ml per

- under 30 kgs: 0.75 - 1.5 ml per kg per hour
Fluid Resuscitation
Electrical Injury
Fluid Resuscitation
Electrical Injury
• Consult Burn Center
• Maintain urinary output 75 - 100 m1 / hour
• Myoglobinuria

• In consultation with Bu - Mannitol
- Sodium Bicarb
History: AMPLET
History: AMPLET
• Allergies
- medications and environmental
• Medications
- prescription and over-the-counter e J2ast medical history
- illness and injury
• Last meal or drink
• Events and Environment
• Tetanus - 5 yem
- childhood immunizations
- exposure to communicable diseases
Events and Environment
Events and Environment
• Prehospital observations and documentation
• Mechanism of injury
• Potential for associated injuries
• Potential for chemical exposure - meth labs
• Substance use or abuse • Abuse or neglect
- children, older adults, domestic violence
• Intentional injuries
- criminal intent, suicide, gang related, mon
Lab Considerations
Lab Considerations
ABG's and carboxyhemoglobin
- children and diabetics
BUN / Creatinine
Drug and alcohol screen
Type and cross for associated trauma
Diagnostic Procedures
Diagnostic Procedures
• X-rays for associated trauma
X-rays for suspected abuse
Associated injuries
Exposed nerve endings
Increasing pressure from circumferential burns
Inadequate flushing of chemical bums
Cold or hypothermia
Pain Management
Pain Management
• Pain
- bum or other cause?
Medications: IV only - MS 2-5 mg. as needed
- Demerol if allergic to MS
- Versed
• Avoid over-medication - respiratOlY depression
- mask symptoms of associated injuries
- may limit ability to participate in decision making
Causes of Burns to children
Causes of Burns to children
Children under 4
- scalds: tap water and cooking related
- contact bums
- low voltage electrical burns
Children 5 - 8
- flame burns: fire play
• matches, lighters, flammable liquids - high voltage electrical injuries
• Young adults
- cooking related: home and work
- MVCs
Why Children Get Burned?
Why Children Get Burned?
Naturally curious and active
Own actions or actions of others
Lack of, or inadequate, supervision
Danger not perceived by caregiver
Fire play
Imitate others and TV
Less perception of danger
Less control of their environment
Limited ability to respond to danger
Expectations above their capabilities
Child Abuse
Child Abuse
• Scalds
- pour
- running water
Recognition of Child Abuse
Recognition of Child Abuse
Injury and story inconsistent with
developmental age
Inconsistent stories
Blame placed on siblings
Delay in seeking treatment
Bruises or bums in various stages of healing
History of other injuries, domestic violence
Prehospital observations
Gut instincts
•• Reporting
- mandatory
•• Documentation - initial history
- repeat history
- social history evaluation
- photographs
- parental interaction with child
Older Adults
Older Adults
Assessment same as adults
Normal physiological changes
Pre-existing medical problems • Thinner skin
'. Pre-existing malnutrition or dehydration • Abuse or neglect
•• Psychological
Types of Burnss
Types of Burns
- flame, contact, scald and steam, tar
- acid, alkali, organic compounds
- high voltage, low voltage, lightning

• Children under 4 - scalds
• Children 5 - 18 - flame
• Physically or mentally challenged - scalds
• Older adults
- scalds and flame • Males > females
Time and Temperature relationship
Time and Temperature relationship
Comfortable bathing: 96-100
Spa/Jacuzzi: 102-104
1st adult pain 119
Recommended home water heater 120. Time to burn 5 minutes
2nd degree burn 130 5 minutes
2nd degree burn adult 140 10 seconds
2nd degree burn adult 146 3-4 seconds
Fast food coffee-175-183 instantaneous
Boiling 212 instantaneous
Grease frying 300-500
Tar and Asphalt Treatment
Tar and Asphalt Treatment
• Immediate cooling
• Stop the burning process
• Remove as much clothing as possible
• Do not attempt to remove tar or asphalt
Chemical Bums
Chemical Bums
- prevention - use of protective gear and clothing
Chemicals - Tissue Destruction
Chemicals - Tissue Destruction
- due to coagulation necrosis and protein precipitation
- tends to limit the depth of tissue damage
- exception
• hjdrofluonc acid
- liquification necrosis and protein denaturation
- deeper spread of the chemical
- tissue damage more severe
Organic Compounds
- cutaneous damage due to fat solvent action
- dissolves the cell membrane
• Low concentrations (<10%
• Low concentrations (<10%
- severe )pain that may not appear for 6 - 18 hours •
Higher concentrations
- immediate, intense pain
- tissue necrosis
• Flood wound with water
• Topical calcium gel to neutralize the fluoride
- one amp calcium gluconate and 100 gm lubricating jelly
- apply with gloved hand
- avoid exposure to other areas
• Cardiac monitoring
• IV
• Monitor calcium levels - may need replacement
• Burn Center - early surgical excision may be necessary
Anhydrous Ammonia
Anhydrous Ammonia
• Rapidly absorbed by mucosal surfaces - eyes, throat, lungs
- deceptive depth
- pain
- burning, tearing, severe pain
- permanent damage to cornea and lens
Anhydrous Ammonia Treatment
Anhydrous Ammonia Treatment
Protect self
Remove patient to fresh air
- flood with water
- 20 minutes or until smell of ammonia is gone
- irrigate
- ophthalmology consult
- oxygen, intubate, ventilatory support
Anhydrous Ammonia
Severity of Injury
- depth of injury
- extent of BSA involved
• Mechanism of action of the chemical
• Duration of contact
• Inconsistent or unusual story
• Pattern of injury inconsistent with story •• Walk ins or drop offs
• Increased morbidity and mortality
• Require at least twice the estimated fluids for resuscitation
• Early
- pulmonary hypertension
- heart failure / MI
- arrhythmias
- renal insufficiency and failure
• Death
- 40% TBSA bum = 100% mortaliry
Treatment principles
Treatment principles
Protect self
Stop progression of injury
Remove all clothing
Immedite irrigation
-20 to 30 minutes
Decreases concentration
-decreases severity of inury
Treatment delays
-tissue destruction continues.
Treatment of Chemical Burns
Treatment of Chemical Burns
• No chemical neutralization - delays treatment
- exothermic reaction can increase damage
• Proper disposal of contaminated articles
• Decontamination of personnel and equipment
Chemical Bums - Conclusion
Chemical Bums - Conclusion
• Insidious injuries
- initial assessment deceptive
- systemic and toxic effects
- delayed effects
• May cause extensive tissue damage without pain
• Often hidden burns
- gasses I vapors underneath clothing
- may not damage clothing
Chemical Bums - Conclusion Prevention
Chemical Bums - Conclusion
• Prevention
- home and work
• Protect yourself
• Initial assessment may be deceptive
• Outcome dependent on - interval between injury
- timeliness of treatment
- appropriateness of treatment
• Referral to Bum Center
- measurement of the amount of electrical current
- what hurts and kills people
• Volts
- the pressure of the current
- affects how the person is hurt
- the earth or something in contact with the ground
- completes the circuit
Electrical Injuries - :High Voltage
Electrical Injuries - :High Voltage
Greater than 1,000 volts • Occupational
lines people
- electricians
- firefighters, EMS, Law Enforcement
• During and following storms • Recreation
- flying kites and climbing trees
• Risk-taking behaviors
• Lightning
Tissue Resistance most to least
• Tissue Resistance most to least
- bone
- fat
- tendon
- skin
- muscles
- vessels
- nerve
Management of Electrical Burns
Management of Electrical Burns

• Primary Survey
- Airway with C-spine protection
- Breathing
- Circulation, Cardiac status
-CPR & defibrillation
-cardiac monitor
-peripheral circulation
- Disability, Deformity, Neuro Deficit
- Expose and Examine
- stop the burning process
Management of Electrical Burn
• Secondary Survey
Management of Electrical Burn
• Secondary Survey - history
- head-to- toe exam
- locate all contact points
- estimate surface bum area
- neurologic exam I changes in LOC
- left hand
- left flank
Wound Management
• Stop the burning
Wound Management
• Stop the burning process
• Adequate flushing of chemicals
• Do not cleanse or debride prior to transfer
• Do not apply topical ointments or creams
• dean, dry covering
• Do not wrap individual body parts
• Maintain body temperature
- warm environment, blankets, monitor closely
• History and physical
• Lab and x-ray results
• EKG strip
• Vital signs
• Physician and nursing notes
• Intake and output
• Treatment provided and response
• Advance directives and/or durable power of attorney for health care