Burn Injury Lecture.ppt
- 1. Epidemiology Tissue injury caused by thermal, electrical, or chemical agents Can be fatal, disfiguring, or incapacitating ~ 1.25 million burn injuries per year • 45,000 hospitalized per year • 4500 die per year (3750 from housefires) 3rd largest cause of accidental death
- 2. Risk Factors Fire/Combustion • Firefighter • Industrial Worker • Occupant of burning structures Chemical Exposure • Industrial Worker Electrical Exposure • Electrician • Electrical Power Distribution Worker
- 3. Anatomy and Physiology of Skin
- 4. Skin Largest body organ. Much more than a passive organ. • Protects underlying tissues from injury • Temperature regulation • Acts as water tight seal, keeping body fluids in • Sensory organ
- 5. Skin Injuries to skin which result in loss, have problems with: • Infection • Inability to maintain normal water balance • Inability to maintain body temperature
- 6. Skin Two layers • Epidermis • Dermis Epidermis • Outer cells are dead • Act as protection and form water tight seal
- 7. Skin Epidermis • Deeper layers divide to produce the stratum corneum and also contain pigment to protect against UV radiation Dermis • Consists of tough, elastic connective tissue which contains specialized structures
- 8. Skin Dermis - Specialized Structures • Nerve endings • Blood vessels • Sweat glands • Oil glands - keep skin waterproof, usually discharges around hair shafts • Hair follicles - produce hair from hair root or papilla – Each follicle has a small muscle (arrectus pillorum) which can pull the hair upright and cause goose flesh
- 9. Pathophysiology of Burns: Potential complications • Fluid and Electrolyte loss Hypovolemia • Hypothermia, Infection, Acidosis • catecholamine release, vasoconstriction • Renal or hepatic failure
- 10. Assessment of Burn Injury: An important step in management is to determine depth and extent of damage to determine where and how the patient should be treated
- 11. Types of Burn Injuries Thermal burn • Flame • Scalding Chemical burn • Acid • Alkali Electrical burn • Lightning Radiation burn
- 12. Depth Classification Superficial ( 1st Degree) Partial thickness (2nd Degree) Full thickness (3rd Degree)
- 13. Burn Classifications 1st degree (Superficial burn) • Involves the epidermis • Characterized by reddening • Tenderness and Pain • Increased warmth • Edema may occur, but no blistering • Burn blanches under pressure • Example - sunburn • Usually heal in ~ 7 days
- 14. Burn Classifications First Degree Burn (Superficial Burn)
- 15. Burn Classifications 2nd degree (Partial Thickness) • Damage extends through the epidermis and involves the dermis. • Not enough to interfere with regeneration of the epithelium • Moist, shiny appearance • Salmon pink to red color • Painful • Does not have to blister to be 2nd degree • Usually heal in ~7-21 days
- 16. Burn Classifications 2nd Degree Burn (Partial Thickness Burn)
- 17. Burn Classifications 3rd degree (Full Thickness) • Both epidermis and dermis are destroyed with burning into SQ fat • Thick, dry appearance • Pearly gray or charred black color • Painless - nerve endings are destroyed • Pain is due to intermixing of 2nd degree • May be minor bleeding • Cannot heal and require grafting
- 18. Burn Classifications 3rd Degree Burn (Full Thickness burn)
- 19. Body Surface Area Estimation Rule of Nines • Adult Palm Rule
- 20. Body Surface Area Estimation Rule of Nines • Peds – For each yr over 1 yoa, subtract 1% from head and add equally to legs Palm Rule
- 22. Pediatric Burns Thin skin • increases severity of burning relative to adults Large surface/volume ratio • rapid fluid loss • increased heat loss hypothermia Delicate balance between dehydration and overhydration Immature immunological response sepsis Always consider possibility of child abuse
- 23. Burn Patient Severity Factors to Consider • Depth or Classification • Body Surface area burned • Age: Adult vs Pediatric • Preexisting medical conditions • Associated Trauma – blast injury – fall injury – airway compromise – child abuse
- 24. Burn Patient Severity Patient age • Less than 2 or greater than 55 • Have increased incidence of complication Burn configuration • Circumferential burns can cause total occlusion of circulation to an area due to edema • Restrict ventilation if encircle the chest • Burns on joint area can cause disability due to scar formation
- 25. Minor Burn Criteria 30 < 2% BSA 20 < 15% BSA • <10% pediatric 10 < 20% BSA
- 26. Moderate Burn Criteria 30 2-10% BSA 20 15-30% BSA • 10-20% pediatric Excluding hands, face, feet, or genitalia Without complicating factors
- 27. Critical Burn Criteria 30 > 10% BSA 20 > 30% BSA • >20% pediatric Burns with respiratory injury Hands, face, feet, or genitalia Burns complicated by other trauma Underlying health problems Electrical and deep chemical burns
- 28. Thermal Burn Injury Pathophysiology Emergent phase • Response to pain catecholamine release Fluid shift phase • massive shift of fluid - intravascular extravascular Hypermetabolic phase • demand for nutrients repair tissue damage Resolution phase • scar tissue and remodeling of tissue
- 29. Thermal Burn Injury Pathophysiology Eschar formation • Skin denaturing – hard and leathery • Skin constricts over wound – increased pressure underneath – restricts blood flow • Respiratory compromise – secondary to circumferential eschar around the thorax • Circulatory compromise – secondary to circumferential eschar around extremity
- 30. Assessment & Management - Thermal Injury Airway and Breathing • Assess for potential airway involvement – soot or singing involving mouth, nose, hair, face, facial hair – coughing, black sputum – enclosed fire environment • Assist ventilations as needed • 100% oxygen via NRB if: – Moderate or critical burn – Patient unconscious – Signs of possible airway burn/inhalation injury – History of exposure to carbon monoxide or smoke
- 31. Assessment & Management - Thermal Injury Airway and Breathing (cont) • Respiratory rates are unreliable due to toxic combustion product’s – May cause depressant effects • Be prepared to intubate early if patient has inhalation injuries – Prep early for RSI
- 32. Assessment & Management - Thermal Injury Circulatory Status • Burns do not cause rapid onset of hypovolemic shock • If shock is present, look for other injuries • Circumferential burns may cause decreased perfusion to extremity
- 33. Assessment & Management - Thermal Injury Consider Fluid Therapy for • >10% BSA 30 • >15% BSA 20 • >30-50% BSA 10 with accompanying 20 LR using Parkland Burn Formula • 4 (2-4) cc/kg/% burn • 1/2 in first 8 hours • 1/2 over 2nd 16 hours
- 34. Management - Thermal Injury Fluid therapy • Objective – HR < 110/minute – Normal sensorium (awake, alert, oriented) – Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi) – Resuscitation formula’s provide estimates, adjust to individual patient responses • Start through burn if necessary, upper extremities preferred • Monitor for Pulmonary Edema
- 35. IV fluid Computation: 70 kg. person with 60% BSB 4 cc./kg./BSB (Parkland Formula) 4 x 70 x 60 = 16800 cc. of Plain LR Give ½ in 8 hrs. (16800/2 = 8400 cc in 8 hrs.) or 1050 cc/hr. x 8 hrs. Give ½ in the next 16 hours: 8400/16 = 525 cc. x 16 hrs.
- 36. Management - Thermal Injury Analgesia • Morphine Sulfate – 2-3 mg repeated q 10 minutes titrated to adequate ventilations and blood pressure – 0.1 mg/kg for pediatric – May require large but tolerable total doses –Tetanus Prophylaxis –Prevention of Curling’s Ulcer –Antibiotics
- 37. Management - Thermal Injury Treat Burn Wound • Low priority - After ABC’s and initiation of IV’s • Do not rupture blisters • Cover with sterile dressings
- 38. Inhalation Injury Anticipate respiratory problems: • Head, Face, Neck or Chest • Nasal or eyebrow hairs are singed • Hoarseness, tachypnea, drooling present • Loss of consciousness in burned area • Nasal/Oral mucosa red or dry • Soot in mouth or nose • Coughing up black sputum • In enclosed burning area (e.g. small apartment)
- 39. Inhalation Injury Burned or exposed to products of combustion in closed space Cough present, especially if productive of carbonaceous sputum Any patient in fire has potential of hypoxia and Carbon monoxide poisoning
- 40. Inhalation Injury Supraglottic Injury • Susceptible to injury from high temperatures • May result in immediate edema of pharynx and larynx – Brassy cough – Stridor – Hoarseness – Carbonaceous sputum – Facial burns
- 41. Inhalation Injury Subglottic Injury • Rare injury • Injury to Lung parenchyma • Usually due to superheated steam, aspiration of scalding liquid, or inhalation of toxic chemicals • May be immediate but usually delayed – Wheezing or Crackles – Productive cough – Bronchospasm
- 42. Inhalation injury Other Considerations • Toxic gas inhalation • Smoke inhalation • Carbon Monoxide poisoning • Thiocyanate poisoning • Thermal burns • Chemical burns
- 43. Inhalation Injury Management Airway, Oxygenation and Ventilation • Assess for airway edema early and often • Consider early intubation, RSI • When in doubt oxygenate and ventilate • High flow oxygen • Bronchodilators may be considered if bronchospasm present • Diuretics not appropriate for pulmonary edema
- 44. Chemical Burns Usually associated with industrial exposure First Consideration: Should you be here? • Does the patient need decontamination before treatment? Burning will continue as long as the chemical is on the skin
- 45. Chemical Burns Acids • Immediate coagulation-type necrosis creating an eschar though self-limiting injury – coagulation of protein results in necrosis in which affected cells or tissue are converted into a dry, dull, homogeneous eosinophilic mass without nuclei
- 46. Chemical Burns Bases (Alkali) • Liquefactive necrosis with continued penetration into deeper tissue resulting in extensive injury – characterized by dull, opaque, partly or completely fluid remains of tissue Dry Chemicals • Exothermic reaction with water
- 47. Chemical Burn Management Definitive treatment is to get the chemical off! Begin washing immediately - removal the patient’s clothing as you wash • Watch for the socks and shoes, they trap chemicals
- 48. Chemical Burn Management Liquid Chemicals • wash off with copious amounts of fluid Dry Chemicals • brush away as much of the chemicals as possible • then wash off with large quantities of water Flush for 20-30 minutes to remove all chemicals
- 49. Chemical Burn Management Do not attempt neutralization • can cause additional chemical or thermal burns from the heat of neutralization Assess and Deliver secondary care as with other thermal and inhalation burns
- 50. Electrical Burns Usually follows accidental contact with exposed object conducting electricity • Electrically powered devices • Electrical wiring • Power transmission lines Can also result from Lightning Damage depends on intensity of current
- 51. Electrical Burns Current kills, voltage simply determines whether current can enter the body • Ohm’s law: I=V/R Electrical follows shortest path to ground Low Voltage • usually cannot enter body unless: – Skin is broken or moist – Low Resistance (follows blood vessels/nerves) High Voltage • easily overcomes resistance
- 52. Electrical Burns Severity depends upon: • what tissue current passes through • width or extent of the current pathway • AC or DC • duration of current contact
- 53. Electrical Burns Alternating Current (AC) • Tetanic muscle contraction may occur resulting in: – Muscle injury – Tendon Rupture – Joint Dislocation – Fractures • Spasms may keep patient from freeing oneself from current
- 54. Electrical Burns Contact with Alternating Current can also result in: • Cardiac arrhythmias • Apnea • Seizures
- 55. Electrical Burns In addition to contact burns, patients can also develop flash burns when the current arcs near them • Flame burns may occur when clothing ignites after exposure to electrical current
- 56. Electrical Burns Pathophysiology of Injuries • External Burn • Internal Burn • Musculoskeletal injury • Cardiovascular injury • Respiratory injury • Neurologic injury • Rhabdomyolysis and Renal injury
- 57. Electrical Burn Management Make sure current is off • Lightning hazards • Do not go near patient until current is off ABC’s • Ventilate and perform CPR as needed • Oxygen • ECG monitoring – Treat dysrhythmias
- 58. Electrical Burn Management Any patient with an electrical burn regardless of how trivial it looks needs to go to the hospital. There is no way to tell how bad the burn is on the inside by the way it looks on the outside.
- 59. THANK YOU