Burns 2011 x6

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Burns

HFB 2216 Paramedic Clinical Science 2

Liz Thyer

Room 3s20

[email protected]

PLEASE NOTE

In light of the Black Saturday bushfires some studentsmay find the following topic to be distressing.Students who feel they would be more comfortablenot attending the lecture are welcome to make atime to see me if they require clarification of thenotes.

If you are experiencing continued distress pleasecontact Student counselling services on 9919 2399or a Victoria University /AV Peer Support staffmember.

Learning Objectives

Describe the pathophysiological response to and systemiccomplications of burn injury.

Classify burn injury according to established standards. Describe the pre-hospital management of the patient who

has a burn injury. . Describe the epidemiology, incidence risk factors, and

prevention strategies of burn injuries.

Identify and describe types of burn injuries, including athermal burn, an inhalation burn, a chemical burn, anelectrical burn, and a radiation exposure.

Learning Objectives

Identify and describe methods for determining bodysurface area percentage of a burn injury includingthe "rules of nines," the "Lund and Browder" chartand other methods

Differentiate criteria for determinin the severit of aburn injury between a paediatric patient and an adultpatient.

Discuss conditions associated with burn injuries,including trauma, blast injuries, airway compromise,respiratory compromise, and child abuse.

Describe the management of a burn injury

Readings

Sanders Ch 23

McCance Ch 45

Epidemiology

Approximately 1% of the population of Australia andNew Zealand (220,000) suffer burns each year.

50% of those will suffer some daily living activityrestriction.

10% will re uire hos italisation.

10% of these are in severe l ife threat.

A severe burn may cost in the order of $250,000 forthe acute hospital care and rehabilitation as well astime off work.

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Epidemiology

Burns constitute only small proportion of

all injury deaths in Australia. People aged 15-24 reported the highest

rate of burns.

burn deaths in 1995 (69%) and a third ofthe deaths from this cause were childrenaged less than 15 years.

INJURED BY BURN OR SCALDby Age group - 2001

Epdemiology

Burns

Cause of burns:

Carelessness 42%

Accident 36%

Other combined 22%

Place of burning:

Home 61% Work 17%

Roadway 10%

Outdoors 8%

Burns

Cause of burn:

Explosion / flame 48%

Scald oil/water 33%

Contact 8%

Electrical 5% Chemical 3%

Friction or sun 3%

Pathophysiology

Skin is the largest organ in the body

Functions

To prevent water loss via evaporation

Temperature regulation

Pathophysiological effect will be dependentupon the surface area covered by the burnand the depth of the burn

Burn Classifications

When classifying burns in the pre-hospital field consideration is made forthe following:

Depth

Surface area

Location

Cause

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Burn Classifications

Burns classifications according to depth can bemade into three types:

Superficial (old terminology first-degree)

Partial thickness (old terminology second-degree)

Full thickness (old terminology third-degree)

Superficial Burns

Only involve the epidermis Pain and swelling normally subsides within

48 hours

Usuall full healed within 7 da s

Sunburn is an example

Bullae may appear, but only after 24 hours

Partial Thickness

This involves the destruction of the epidermisand superficial dermis

The burned area appears blistered

superficial partial thickness and

deep partial thickness

Partial Thickness

Superficial partial thickness Bright red and moist

Very sensitive to stimulus

Heal in 2-3 weeks

Minimal scarring

Deep partial thickness Dark red or yellow white

Take longer than 3 weeks to heal hyper-trophicscarring occurs

Few epithelial elements remain

Full Thickness

Involves the epidermis and dermis includingthe dermal appendages

Burn appears charred or pearly white, brown,

Normally without sensation, but can still beconsiderable pain to the patient.

Because of the depth of the burn healing onlyoccurs in the form of scarring or skin graft

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Burn Shock

Relative and absolute fluid loss

Relative

ssue oe ema

Absolute

Evaporation

Cardiac output may drop by 30-50% resulting incardiac depression

Surface Area Classification

Wallace Rule of nines quick and easy to do

usually quite accurate but this reduces withatient a e

Lund and Browder charts

high degree of accuracy for all ages buttime consuming and not easilyremembered

Palmar method

Wallace Rule Of Nines

Lund And Browder Chart Paediatric Rule of Nines

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Burn Classification Minor Burns

20% in patients of any age group

Full thickness burns of BSA > 5%

Known inhalation injury Significant burn to face, hands, feet, genitalia,

perineum or major joints Significant associated injuries

Will need admission to a burn centre

American Burn Association Grading System

Burn Type Classification

Thermal

Chemical

Electrical

Radiation

Thermal Burns

Thermal Burns

Most common type of burn

Risk is highest in the 18 35 year olds

High incidence of scalding in 1 5s

Soft tissue is burned when it is exposed toempera ures a ove a oug mecan influence burn, 44 >6hours =burn)

Rate of dermal necrosis doubles with eachdegree rise 46-51, necrosis in

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Thermal Burns

Thermal burns cause coagulation of soft tissue Leading to:

soft tissue temperature increases

capillary permeability increases

fluid loss occurs

plasma viscosity increases

resultant microthrombi formation

Burns cause an increased metabolic rate andenergy metabolism, which could affect thepatients presenting condition

Thermal Burns

Three Distinct zones of injury: Zone of coagulation Centre of wound, area of most intense contact Coagulation necrosis of cells, nonviable

Zone of Stasis , Ischaemic cells because of clotting and

vasoconstriction, die within 24-48 hours

Zone of Hyperaemia At the periphery of the wound, viable Increased blood flow due to inflammatory response Recovers in 7-10 days if no infection or shock

Jacksons Burn Wound Model Thermal BurnsInjury

Initially brief decrease in blood flow to area and Arteriolar vasodilation

Release of chemical mediators and vasoactive substances

Cause increase in capillary permeability

Fluid shift from intravascular space into injured tissue

Na K pump also damaged

Na into cells

Water into cells

Increase in osmotic pressure

Causes increase of flow of fluid into wound

Compromised cardiac output due to reduced VR, reducedperipheral blood flow and increased systemic vascular resistance

Thermal Burns

Normal process of evaporation of water to theenvironment is accelerated

Fluid loss (shock) 8-12 hours Decreased venous return Decreased cardiac out ut Increased vascular resistance

Eventually: Haemolysis Rhabdomyolysis Haemoglobinuria ARF Death

Chemical Burns

Majority of chemical burns are from acids andalkalis

Acids

Coagulation

orma on o a oug esc ar a can m ur erdamage

Alkalis

Liquefactive necrosis

Deeper penetration

Also need to consider the toxicity of the substance

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Chemical Burns

Superficial Itching, burning and pain

Partial thickness

Bullae

Full thickness

Damage to the dermis the extent depends onthe chemical, extent and duration of contact

Chemical Burns

Face, eyes and extremities are most commonlyaffected by chemical burns

Mortality rate is lower than for thermal burns butwound healing longer

Mucous membrane irritation is common

Signs and symptoms are generally agent specific

Alkalis may result in burns which initially appearsuperficial but progress to full thickness over time

Chemical Burns - Treatment

If liquid, irrigate with copious fluids

If powder, dust off patient and remove clothing as watermay activate the chemical

Chemical burns to the eye should be treated by running

at least 15 minutes

Always tilt the head so the unaffected eye is uppermost

and does not come in contact with contaminated water. Irrigation should be continued during transport and until

reaching specialist medical assistance

DO NOT water irrigate calcium, lithium ormagnesium burns

Chemical Burns

Metals

Molten metals thermal burns

Sodium, Lithium, potassium, magnesium, calciumand aluminium can ignite spontaneously in air

Should NOT use water to put it out as intensiveexothermic reaction takes place

Burning metal on the skin or hand should becovered with mineral oil or sand

Electrical Burns

When attending a casualty exposed to electricity,safety is the priority.

Electrical injuries are divided into three categories: low voltage

high voltage

lightning strikes

High voltage electricity will discharge through air. 1000v will clear a few millimetres.

5000v will bridge 10mm

40,000v will clear 130mm.

Electrical Burns

Low voltage is anything below 1000 volts. Domestic AC will cause significant contact wounds

and may cause cardiac arrest but no deep tissuedamage.

High voltage is often 11,000 to 33,000 volts from highens on ca es an can cause n ury n wo ways Flash over discharge passes over the body igniting clothing

but not causing contact wounds. Current transmission results in both surface and deep burns

especially at the entry and exit points.

Deep muscle damage may occur under apparentlynormal skin and may be very extensive and lifethreatening.

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Lightning Strikes

Lightning strikes are extremely high voltage Also high amperage DC discharge of ultra

short duration Lightening injuries have a 25% mortality rate

and water sports accounts for the largestgroup o n ur e s an a a es

Significant injury especially with exit burns tothe feet

Pathway of damage often over rather thanthrough skin

Electrical Burns

Three largest risk groups are toddlers teenagers those who work with electricity

Severity related to: Current type Volts Intensity Resistance Area Duration of contact Environmental factors

Electrical Burns - Symptoms

Contact burns Thermal heating Flash arc and flame thermal burns Blunt trauma Prolonged muscle tetany Skin injury does not correlate well with

underlying damage Low V = VF High V = Asystole Dysrhythmias can occur up to 24 - 48 hrs

later

Electrical Burns

Electrical Burns Treatment

As for thermal burns

MICA

Monitor/ECG

Prehospital Burns Management

Non accidental injury

Emergency responders should be observant tosituations where the injury appears suspiciousdue to Delay in call

Vague or inconsistent history

Presence of other trauma

Certain patterns of injury

Information should be passed onto the receiving hospital

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Stop the burning process Cover the burns with clean cool cloth soaked in cool

water this will dissipate the heat Continue cooling with running water to reduce heat

and swelling, the useful range is between 8 and 25degrees Celsius. Douse with water for at least 20minutes.

Never totally immerse patient in cold water or applyice packs to burn

Prolonged exposure to cold water and ice shouldnever be applied

Elevation of the part


Remove clothing that is not adhered to patient Hot or charred clothing should be removed as quickly as

possible.

Consider removing jewellery if near burnt areas ofthe patient

over e urn w a c ean s er e ress ng an orcling wrap

After stabilising the patient A thorough secondary survey Adequate analgesia Elevate extensively burned limbs whilst maintaining

observation of pulse strength and capillary refill

Rapid transport to appropriate medical facility


Assess and stabilise the airway

Supplemental oxygen 8L/min

Signs of laryngeal oedema indicate a need tointubate

Assess and stabilise circulation IV cannulation in bilateral cubital fossae

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Systemic Complications

Haemodynamic instability Respiratory system involvement

Hypermetabolic response

ys unct on o ot er organ systems

Sepsis

Haemodynamic instability

Hypovolaemic shock associated with: Decrease in venous return

Decreased cardiac output

Increased vascular resistance

Renal failure may occur due to: Haemolysis

Rhabdomyolysis


Fluid replacement for extended managementfollows set formula

Parkland formula: Most commonly used:

4mls/kg x % BSA over 24 hours

With half to be given in the first 8 hoursafterinjury

This is NOT what is used in AV!


Initial fluid formula in adults for emergency ambulance is:

% of Burn Surface Area x Weight (kg) over 2 hours(from time of burn)

full thickness only).

For example: 50% burn surface area x 80kg patient = 4000mls

Normal Saline solution to be administered in two hoursfrom time of burn.


Initial fluid formula in paediatrics for emergencyambulance is:

3x % of Burn Surface Area x Weight (kg) =amount of fluid in first 24hours

Burn surface area measured as a percentage(partial and full thickness only).

For example: 3 x 50% burn surface area x 20kg patient = 3000mls

Hartmanns solution with 1500ml to be administered infirst 8 hours.

Respiratory system involvement

These are also known as inhalation burns The result of inhaling hot gases

Inhalation injury increases mortality in ALLburns by up to 40%

45% of patient with burns to face will have aninhalation injury

All suspected inhalation burns should beregarded as time critical

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Respiratory system involvement

Pulmonary injury and airway burns should beconsidered in the presence of the following:

History of fire in enclosed space or possible explosion Facial burns or singed nasal/facial hairs Carbonaceous sputum Oedema to face and airways Hoarse voice Stridor, wheezes and / or cough Obvious respiratory distress

Signs and symptoms of pulmonary injury followingan inhalation event, may be delayed for 12 24hours

Hypermetabolic response

Stress of the burn increases the nutritional andmetabolic needs of the body

Characterised by Increase oxygen need

Increased glucose use

Protein and fat wasting

Secrete stress hormones to maintain homeostasis

Heat production is increased to balance heat lossfrom the burned area

Peak is 7-17 days

Dysfunction of other organ systems

Renal failure may occur due to: Haemolysis Rhabdomyolysis Decreased fluid volume Drugs

Gastric dilation and decreased peristalsis compounded bydrugs

Nervous System Due to periods of hypoxia Fluid volume deficits Electrical burns

Sepsis

May arise from Burn wound

Pneumonia

UTI

n ect on e sew ere

Immunologically the skin is the first line of defence

therefore the body is open to bacterial infection Destruction of the skin also affects delivery of

components of the immune system to their site ofneed

Hospital Management

Tetanus

Nasogastic tube

Escharotomy may

circumferential limbburns

References and Acknowledgements

http://www.alfred.org.au/burns_unit/

Jodie Limon

Documents

Burns 2011 x6