![Complicating Factors Age/gender Chronic disease Circumferential burns Distracting injury Fluid loss [Already compromised] Immune system](https://image.slidesharecdn.com/lesson09-090922231259-phpapp01/85/Lesson-09-23-320.jpg)
Lesson 09
- 1. Lesson 9 Thermal Trauma
- 2. Objectives As a result of active participation in this lesson, you should be able to: Differentiate between critical and noncritical thermally injured patients Differentiate the treatment needs of thermally injured patients based on depth of injury, body surface area involved, mechanism of burn, and coexisting injuries and health conditions Discuss the specific needs of thermally injured patients related to fluid resuscitation, pain management, and thermoregulation
- 3. Thermal Trauma WHO statistics for 2002 estimates 322,000 deaths worldwide due to smoke, fire, and flames A large percentage of burns are a result of intentional injury, particularly against children, women, and the elderly
- 4. Thermal Trauma Burns are not just isolated to skin; large burns are a multisystem injury capable of life-threatening affects to the heart, lungs, kidneys, GI tract, and immune system Most common causes of death relative to burn injuries are complications and respiratory failure
- 5. Scenario You are dispatched to a suburban home on a cool, sunny fall day in response to a potential burn patient. The fire department also has responded. On your arrival you are informed by a member of the fire department that the 35-year-old male patient used an accelerant in a metal trash receptacle with intent to burn garbage and yard debris.
- 6. Scenario: Scene Size-Up What are the considerations for scene safety? What are the potential injuries associated with this mechanism?
- 7. Scenario The scene has been secured by the fire department. The patient is standing upright with both arms extended and appears to be in considerable pain and distress. Most of the patient's upper torso is bare with the exception of small patches of burnt clothing that remain. Most of the patient’s hair has been burned off, and you can see varying skin discolorations from your vantage point.
- 8. Primary Survey Patient is awake, is in obvious pain, and has great difficulty responding verbally. You note sounds of stridor on inspiration. You determine the presence of reddened skin and blistering to the anterior chest and upper extremities, and what appears to be ‘raw’ flesh in the neck and facial area. All facial hair and most scalp hair has been burned off.
- 9. Scenario: Critical Thinking Does your assessment of this patient indicate an inhalation injury? How does this affect your treatment of this patient?
- 10. Inhalation Injury Thermal Dry air vs. steam Asphyxiation/smoke inhalation Carbon monoxide Cyanide gas Particulate matter Delayed toxin-induced lung injury May manifest after several days Severity related to composition of inhaled gas and duration of exposure
- 11. Signs of Inhalation Injury Singed or absent facial hair Facial burns Difficulty speaking, hoarseness, or stridor Soot in oropharynx Oropharyngeal edema Crackles auscultated in lungs Respiratory failure
- 12. Inhalation Injury: Treatment Early intubation before airway becomes occluded High-flow oxygen Rapid transport to an appropriate facility Early and aggressive airway management is critical for patients with inhalation injury!
- 13. Scenario: Treatment Stop the burning process! What are the patient’s immediate airway needs? Does this patient require assisted ventilations?
- 14. Scenario: Critical Thinking What degree/thickness of burns are likely in this patient? Which type of injury is likely causing your patient’s pain? Does the degree/thickness of burns alone make this a critical patient? Why or why not?
- 15. Fluid Resuscitation Most critical to preventing hypovolemic shock; second only to airway in early burn treatment Preference is for lactated Ringer’s solution Avoid starting IVs in burned tissue, where edema can make veins difficult to find and lines difficult to secure Patients with both thermal and smoke inhalation require additional fluids over what would be given patient with thermal burns only; withholding fluids aggravates the severity of pulmonary injury
- 16. Fluid Resuscitation: Parkland Formula Calculates the fluid required during the initial 24 hours from point of injury 4 mL/kg/%TBSA burn Divide the 24-hr value by 2 to determine fluid value to be given from time of injury to hour 8 Divide total by 8 for hourly rate
- 17. Critical Thinking Is this patient’s circulation compromised? Calculate appropriate fluid resuscitation for a patient weighing 80 kg and with 36% body surface area burns using the Parkland formula. How would you administer these fluids?
- 18. Anatomy of the Skin Epidermis (outermost layer) Dermis (nerve endings, blood vessels) Subcutaneous (fat and muscle)
- 19. Determining the Severity of Burns First-Degree or Superficial Burns Involves the epidermis Red and painful Second-Degree or Partial-Thickness Burns Involves the epidermis and potentially some portion of the dermis Blisters and/or glistening or wet base Third-Degree or Full-Thickness Burns Thick, dry, white leathery Visible thrombosis of blood vessels Fourth-Degree Burns Involves all layers of skin, fat, bone, and underlying organs
- 20. Scenario: Critical Thinking What degree/thickness of burns does your observation of this patient indicate? Which of these values is likely causing your patient’s pain? Do these values alone indicate a critical patient? Why or why not?
- 21. Rule of Nines
- 22. Scenario: Critical Thinking What percent of body surface area (BSA) burns does your observation of this patient indicate? Does this value alone indicate a critical patient? Why or why not? How does this value affect your treatment?
- 23. Complicating Factors Age/gender Chronic disease Circumferential burns Distracting injury Fluid loss [Already compromised] Immune system
- 24. Scenario: How would you treat this patient? Stop the burning process! What are the patient’s airway needs? Does this patient require assisted ventilations?
- 25. Scenario: How would you treat this patient? What can be done to improve the patient’s circulation?
- 26. Wound Dressing Dry sterile dressings Wet dressings only when BSA is less than 10% Keep burn areas covered to reduce pain Do not remove clothing that has adhered to skin Do not break blisters prehospital Do not apply ointments, salves, or gels
- 27. Scenario: How would you treat this patient? What kinds of wound dressings would you apply to this patient? Is the loss of body heat a consideration with this patient?
- 28. Scenario: How would you treat this patient? Does this patient require pain management?
- 29. Pain Management Ensure afflicted areas are covered Airflow across burn area causes pain Follow local protocols for pharmacological interventions
- 30. Scenario: How would you treat this patient? What transport decisions are involved with this patient?
- 31. Chemical Burns Can be classified as: Acid — pH of 7 (neutral) to 0 (strong acid) Base — pH of 7 to 14 Organic (i.e., gasoline) Inorganic (i.e., hydrofluoric acid)
- 32. Chemical Burns Ensure scene safety for you, your partner, and your patient Wear protective gear In most cases, flushing the affected area with copious amounts of water will dilute and remove the chemical Powdered chemicals should be brushed off first
- 33. Chemical Burns If protocol is unknown, contact the nearest poison control center Material Safety Data Sheets (MSDS) should be transported along with patient Chemical burns of the eyes should be flushed with water continuously Morgan lens is a useful adjunct Treat all chemical burn patients as critical
- 34. Electrical Burns Can be classified as: Current burns Arc (flash) Contact burns
- 35. Electrical Burns Injury can include: Thermal burns Altered mentation Intracranial bleeding Partial or full paralysis Cardiac arrhythmias Kidney failure Associative injuries Ruptured tympanic membranes Spinal and long bone fractures
- 36. Electrical Burns Ensure scene safety for you, your partner, and your patient Immobilize spine if fractures are detected or suspected Administer IV lactated Ringer’s or normal saline to flush myoglobin and prevent kidney damage
- 37. Patients Requiring Burn Centers Inhalation injury Second/third-degree burns in children under 10 years of age or adults older than 50 years of age Second/third-degree burns of more than 20% TBSA Second/third-degree burns involving face, hands, feet, genitalia, perineum, and major joints
- 38. Patients Requiring Burn Centers Second/third-degree burns with complicating trauma where burn poses greatest risk Chemical burns Electrical burns Patients with preexisting medical disorders
- 39. Summary Thermal trauma is a significant cause of morbidity and mortality Immediate concerns are for airway, breathing, and circulation Large burns are a multisystem problem EMS providers play a critical role in recognizing burn center criteria and in the initial management of burn patients
- 40. QUESTIONS?
Editor's Notes
- #4: Instructor Notes: WHO publishes a fact sheet “Facts about injuries: burns (2004)” available from their website for download in .pdf (291kb). Go to http://www.who.int/violence_injury_prevention/publications/factsheets/en/ The statistics provided do not include deaths resulting from other types of burns such as chemical or electrical burns. It is important to research statistical facts relevant to the participants, system, and environment you are teaching in (i.e., in the U.S.A., each year approx. 61,000 hospitalizations are due to burn injury). The Internet is a great tool for doing research. The WHO site is a good one to search, as is the National Center for Injury Prevention and Control for the U.S.A. (http://www.cdc.gov/ncipc/wisqars/) Key Points: Intentional injury is a serious concern, and all circumstances relative to such potential should be taken into account. Consider your local protocols for reporting such abuses. The potential for distraction by burn injury may interfere with patient care, such as maintaining good airway and treating for shock.
- #5: Instructor Notes: Key Points: Physiologic response to thermal injury is both local and systemic. Direct tissue injury causes increased capillary permeability, edema, and evaporative fluid loss. Systemic response is also due to increased capillary permeability: flux of fluid and electrolytes in circulation results in generalized edema, circulatory hypovolemia, and hyperviscosity (burn shock). Impaired cardiac function, increased pulmonary vascular resistance, decreased myocardial contractility Kidney, GI organs, and peripheral tissues are hypoperfused Tissue ischemia Acidosis Inhalation injury may be exacerbated by pulmonary edema
- #7: Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. For example, if participants respond with a list of potential injuries, follow up with questions such as “What makes you say that?” This verifies understanding of the mechanism of injury. Key Points: Primary scene safety consideration is the accelerant and any remaining fire. Remember to take BSI precautions. The mechanism is suspicious for burns, smoke and/or heated gas inhalation, secondary injuries, or tertiary traumatic injury.
- #9: Key Points: Consider that burns to the neck/torso and upper extremities may make the carotid and radial sites unavailable for assessment of pulse rate. What other sites might you consider if this were the case?
- #10: Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: Inhalation injury of the upper airway is indicated by facial burns, difficulty speaking, stridor. A patent airway is critical. Transport without delay.
- #11: Key Points: Most thermal inhalation injury presents in the upper airway (supraglottic) structures. Dry air is a poor conductor of heat. Large surface areas of nasopharynx cool the heated air before it reaches the vocal cords. Vocal cords adduct (close) by reflex, further protecting lower structures. Steam has 4,000 times the heat-carrying capacity as dry air and can cause significant damage to lower (infraglottic) airway structures. Steam injuries are rare. Carbon monoxide (CO) causes death by cellular hypoxia or asphyxia. Inadequate delivery of oxygen to the tissues CO binds to hemoglobin with a greater affinity than oxygen Treatment: remove from source and administer high-flow oxygen Cyanide gas is produced by burning plastics. Disrupts body’s ability to use oxygen to produce energy Treatment: rapid transport to ED with access to antidote therapy
- #13: Key Points: What is an appropriate facility in your location, considering transport times and levels of care available? Specialized burn care Access to immediate surgical interventions Unique modes of mechanical ventilation Hyperbaric oxygenation for CO poisoning
- #14: Key Points: Stop the burning with tepid water Manage the airway BLS: high-flow oxygen, rapid transport, assist ventilations as appropriate, call ALS back-up if available ALS: consider intubation and assisted ventilation; use pharmacological intervention with extreme caution
- #16: Key Points: Potential for massive fluid shifts due to edema Evaporative losses at burn site Fluid resuscitation aimed at not only replacing immediate fluid deficits but also anticipating loss of further fluids over the next 24 hours
- #18: Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: Accurate blood pressure also may be difficult to ascertain: Burns to extremities may not allow placement of a BP cuff. Circumferential burns, full-thickness burns, and edema to the extremities may reduce distal limb perfusion. Regardless of actual BP value, this patient’s circulation will be compromised by his body’s response to the burn. Parkland formula (4 mL × BSA × weight in kg) 24-hour value = 11520 mL Half to be delivered within first 8 hours after injury (11520 mL/2 = 5760 mL) Hourly rate is 5760 mL/8 hrs = 720 mL/hour
- #19: Key Points: Skin is the largest organ in the body. Skin serves many functions: Protection from external environment Regulation of fluids Thermoregulation Sensation Metabolic adaptation
- #20: Key Points: Burn severity may be difficult to accurately assess in the field. Burn trauma is a dynamic process in that a burn may transition from one level of severity to another.
- #21: Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: Although it is difficult to assess burn depth accurately in the field, visual indications are that this patient has sustained first- and second-degree burns. Pain is usually present for all burns except fourth degree. Even though there is extensive tissue damage in third-degree burns, there are usually areas of second-degree tissue burns surrounding the third-degree burns, which account for the pain. These values alone usually require surface area information and estimate of area affected to be meaningful. For example, a first-degree burn can be critical if it covers 90% of a patient’s body; a second-degree burn may be considered manageable if it only covers a 1% portion of a patients arm, whereas 1% of genitalia is critical.
- #22: Key Points: Note the difference in values for child vs. adult in these areas: Head, 18 vs. 7 Leg, 13.5 vs. 18
- #23: Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: 18% value for anterior chest; 4.5% value for each anterior upper extremity; 4.5% value for head. Total = 31.5% As was the case with burn depth, this information alone is less valuable without burn depth and areas affected. Primary survey information along with BSA value, burn depth, and burn areas affected suggest that this patient must be treated and transported immediately.
- #24: Instructor Notes: Ask your students to discuss the relevance and affect of each of these complicating factors. Key Points: Age/gender — skin is thinner in children, women, and the elderly. Chronic disease — additional complications, longer healing process. Circumferential burns — create a tourniquet effect that can restrict blood flow to an extremity or inhibit respiration when the chest is involved. Distracting injury — secondary trauma. Fluid loss — hypovolemic shock. Compromised immune system — difficulty combating infection.
- #25: Key Points: Stop the burning with tepid water. Manage the airway. If BLS, use high-flow oxygen and rapid transport; assist ventilations when appropriate. Call for ALS backup, if available. If ALS, consider intubation and assisted ventilation; pharmacological intervention with extreme caution.
- #26: Key Points: Fluid resuscitation is extremely important with burn patients; it can forestall hypovolemic shock. Elevate burned extremities to reduce edema and improve circulation.
- #28: Key Points: Dry dressings only Cover patient with several blankets and increase heat in unit
- #29: Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: BLS pain management includes covering all burns with dressings. ALS pain management may include narcotics or nitrous oxide; follow local protocol.
- #31: Instructor Notes: Solicit responses from participants rather than supply the information yourself. Ask follow-up questions as needed. Key Points: This patient is considered critical and should be transported without delay to nearest burn centre. If unavailable, consider the nearest trauma center.
- #32: Instructor Notes: Consider researching what types of chemicals local industries are using and encourage participants to make themselves familiar with these.
- #33: Key Points: Most chemicals can be removed with water, but there are exceptions; some are: Dry lime and soda ash Lithium and sodium metal Hydrogen fluoride and hydrofluoric acids Become familiar with the domestic and industrial chemicals used in your area.
- #34: Instructor Notes: Obtain the Poison Control Center contact information for your area or country. U.S.A. providers also can access CHEMTREC at 1.800.424.9300 for chemical information. Key Points: Material Safety Data Sheets (MSDS) should be transported along with the patient for hospital use, if available.
- #35: Key Points: Current burns occur when an electrical current passes through tissue. Typically, entrance and exit wounds are present. Arc (flash) burns occur when tissue comes in contact with the superheated air associated with an arcing of electricity between two contact points. Contact burns occur when electrically heated metal comes in contact with tissue.
- #37: Key Points: Spinal immobilization Intense and sustained muscle contractions can fracture spines and long bones. Lightening strikes often ‘throw’ the victim, causing secondary traumatic injury.