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66 Cards in this Set
- Front
- Back
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The Burn depth is determined by:
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TEMPERATURE
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. |
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Burn Zones:
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Zone of coagulation
Zone of stasis: effected by hypothermia, inadequate fluid resuscitation, and inadequate tissue perfusion Zone of hyperemia (redness) |
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First degree Burn: Superficial-describe
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Epidermis only
Pink to red Painful NO BLISTERS 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!! |
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Treatment of First degree burns
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Fluids
Over the counter pain meds -NSAIDs Monitor for fever Cool showers or baths Moisturization Aloe vera Avoid re-exposure |
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Second degree: Partial thickness
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Epidermis and part of dermis
Heal without surgical intervention BLISTERS VERY PAINFUL Blanches -capillary refill may be prolonged |
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Third Degree: Full Thickness
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Epidermis, Dermis, subcutaneous tissue
Surgical intervention Insensate No blanching/capillary refill Charred, bright red, marbled, leathery, tan, waxy, or pearly white TIGHT, NON ELASTIC |
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Circumferential Full thickness burns
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Assessment
Peripheral pulses Doppler, pulse oximetry Symptoms of circulatory compromise 5 P’s: pain, pallor, pulselessness, progressive paresthesia, paralysis. Cold |
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Management of Circumferential Burns
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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 |
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Outcome of Injury
Dependent on : |
Age
Total body surface area (TBSA) depth of burn Inhalation injury Pre-existing medical history Timeliness of treatment Appropriateness of treatment Adequate fluid resuscitation |
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Local reaction: Immediate
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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 |
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Systemic reaction
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Immune suppression
Hypermetabolism Cardiovascular -decreased circulating volume Initial decreased cardiac output Hypotension, hypoperfusion and hypovolemia Tachycardia Pulmonary Tissue damage with local edema Increased shunting Increased O2 requirements Gastrointestinal Decreased peristalsis and absorption Low blood flow Renal Decreased Urinary output Hemoglobin or myoglobin clogging Low fluid volumes Insert urinary catheter Diuresis after 48-72 hours |
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Primary assessment Life and Limb threatening
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AIRWAY
-with C-spine protection BREATHING CIRCULATION, Cardiac Status, CPR DISABILITY, Deformity, Neurological Deficit EXPOSE, Examine, Environmental Control -stop the burning process |
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AIRWAY and BREATHING
Inhalation injury |
Significant predictor of mortality
Three types: Carbon monoxide Upper airway Thermal Lower airway Smoke Chemical |
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Carbon monoxide
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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 |
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Signs of inhalation injury
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History
-enclosed space fire -explosion -chemicals (meth) -steam 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 |
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Intubation guidelines
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Prehospital
-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. |
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Intubation
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No Succinyl choline
-hyperkalemia in burns Non depolarizing neuromuscular blockers -Pancuronium -Vecuronium Route -Nasal vs. oral Size -Large |
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Circulation, Cardiac Status
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Bleeding
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 -LR |
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Circulation
Initial Fluid Resuscitation |
Two large bore IV’s
-Adults greater than 20% Pediatrics greater than 15% LR Site selection -peripheral: unburned -peripheral: burned -Central lines Femoral only No cutdowns |
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Ideal Body temperature for burned person
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101.5---So, the room temperature may be 110.
Don’t give Tylenol until 102. 5. Get blood culture at 103. |
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Neuro Assessment
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Level of consciousness
Affected by hypoxia, carbon monoxide, head injury, pre-existing mental conditions, drugs, alcohol AVPU Alert Responsive to Verbal stimuli Responsive to Painful stimuli Unresponsive |
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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 |
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Kids-differences
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Relatively larger body surface area
Larger head Little insulation Inability to shiver Assume environmental temperature. |
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Why not cool and wet
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Systemic hypothermia
Localized hypothermia Goose-bumps and shivering Painful rewarming Get-typed blankets and dressings contraindicated |
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Secondary Assessment
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History
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. |
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Percent of burn
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Child: 9% =arm
18%=torso/back 14%=leg 16% = head Adult 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) |
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Prehospital Fluids
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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 |
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Fluid Resuscitation
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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 |
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Pediatric Fluids
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Pediatric Fluids
• Resuscitation fluids -LR - titrate to maintain urine Output • Maintenance fluids -D5LR - constant rate - amount the child would need if healthy and NPO |
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Fluid Resuscitation - Special Needs
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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 |
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Fluid Resuscitation Monitoring
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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 hour - under 30 kgs: 0.75 - 1.5 ml per kg per hour |
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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 |
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History: AMPLET
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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 |
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Events and Environment
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Events and Environment
• Prehospital observations and documentation critical • 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 |
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Lab Considerations
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Lab Considerations
ABG's and carboxyhemoglobin CBC Electrolytes Glucose - children and diabetics BUN / Creatinine Drug and alcohol screen Type and cross for associated trauma |
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Diagnostic Procedures
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Diagnostic Procedures
CXR • X-rays for associated trauma X-rays for suspected abuse • EKG |
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Pain
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Pain
Associated injuries Exposed nerve endings Increasing pressure from circumferential burns Inadequate flushing of chemical bums Cold or hypothermia Psychological |
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Pain Management
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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 |
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Causes of Burns to children
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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 |
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Why Children Get Burned?
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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 |
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Child Abuse
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Child Abuse
• Scalds -immersion - pour - running water Contact Other |
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Recognition of Child Abuse
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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 |
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Abuse
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Abuse
•• Reporting - mandatory •• Documentation - initial history - repeat history - social history evaluation - photographs - parental interaction with child |
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Older Adults
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Older Adults
Assessment same as adults Normal physiological changes Pre-existing medical problems • Thinner skin '. Pre-existing malnutrition or dehydration • Abuse or neglect •• Psychological |
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Types of Burnss
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Types of Burns
Thermal - flame, contact, scald and steam, tar Chemical - acid, alkali, organic compounds Electrical - 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 |
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Time and Temperature relationship
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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 |
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Tar and Asphalt Treatment
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Tar and Asphalt Treatment
• Immediate cooling • Stop the burning process • Remove as much clothing as possible • Do not attempt to remove tar or asphalt |
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Chemical Bums
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Chemical Bums
- prevention - use of protective gear and clothing |
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Chemicals - Tissue Destruction
Acids |
Chemicals - Tissue Destruction
Acids - due to coagulation necrosis and protein precipitation - tends to limit the depth of tissue damage - exception • hjdrofluonc acid Alkalis - 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 |
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• Low concentrations (<10%
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• 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 |
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Anhydrous Ammonia
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Anhydrous Ammonia
• Rapidly absorbed by mucosal surfaces - eyes, throat, lungs Skin - deceptive depth - pain Eyes - burning, tearing, severe pain - permanent damage to cornea and lens |
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Anhydrous Ammonia Treatment
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Anhydrous Ammonia Treatment
Protect self Remove patient to fresh air Skin - flood with water - 20 minutes or until smell of ammonia is gone Eyes - irrigate - ophthalmology consult Respiratory - oxygen, intubate, ventilatory support |
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Anhydrous Ammonia
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Severity of Injury
Agent Concentration - depth of injury Volume - extent of BSA involved • Mechanism of action of the chemical • Duration of contact |
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Methamphetamine
History |
Methamphetamine
History • Inconsistent or unusual story • Pattern of injury inconsistent with story •• Walk ins or drop offs |
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Methamphetamine
Complications |
Methamphetamine
Complications • Increased morbidity and mortality • Require at least twice the estimated fluids for resuscitation • Early - pulmonary hypertension - heart failure / MI - arrhythmias - ARDS - renal insufficiency and failure • Death - 40% TBSA bum = 100% mortaliry |
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Treatment principles
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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. |
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Treatment of Chemical Burns
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Treatment of Chemical Burns
• No chemical neutralization - delays treatment - exothermic reaction can increase damage • Proper disposal of contaminated articles • Decontamination of personnel and equipment |
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Chemical Bums - Conclusion
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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 |
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Chemical Bums - Conclusion Prevention
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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 |
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Electricity
Amps Volts |
Electricity
Amps - measurement of the amount of electrical current - what hurts and kills people • Volts - the pressure of the current - affects how the person is hurt Ground_ - the earth or something in contact with the ground - completes the circuit |
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Electrical Injuries - :High Voltage
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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 |
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Tissue Resistance most to least
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• Tissue Resistance most to least
- bone - fat - tendon - skin - muscles - vessels - nerve |
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Management of Electrical Burns
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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 • |
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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 |
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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 • |
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Documentation
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Documentation
• 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 |
