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Burns in Children Review. Tarek Hazwani, MD Assistant Consultant Pediatric Intensivist King Abdulaziz Medical City. Burns in Children Review. Anatomy of Skin Pathophysiology Critical Factors Management. Anatomy of Skin. Largest body organ More than just a passive covering. Anatomy. - PowerPoint PPT Presentation
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1
Burns in Children Review
Tarek Hazwani MDAssistant Consultant Pediatric Intensivist
King Abdulaziz Medical City
2
Burns in Children Review
Anatomy of Skin Pathophysiology Critical Factors Management
3
Anatomy of Skin
Largest body organ More than just a passive
covering
4
Anatomy
Two layersbull Epidermisbull Dermis
5
Skin Functions
Sensation Protection Temperature regulation Fluid retention
6
Burn Pathophysiology
Loss of fluids Inability to maintain body
temperature Infection
7
Burn Pathophysiology
Patients with large burns (ge15 percent TBSA for young children and ge20 percent for older children and adolescents) develop systemic responses to these mediators
For patients with 40 percent TBSA or more myocardial depression can occur
As a result patients with major burns may become hypotensive (burn shock) and edematous (burn edema)
8
Burn PathophysiologyMetabolic response
Following resuscitation children with major burns develop a hypermetabolic response that results in a dramatic increase in energy expenditure and protein metabolism
Evidence suggests that modulation of the hypermetabolic response with therapies such as beta blockers and human growth hormone may improve outcomes for severely burned children
9
Pathophysiology
Systemic capillary leak usually persists for 18 to 24 hours Protein is lost from the intravascular space during the first 12 to 18 hours after a burn after which vascular integrity improves
10
Critical Factors
Depth Extent
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
2
Burns in Children Review
Anatomy of Skin Pathophysiology Critical Factors Management
3
Anatomy of Skin
Largest body organ More than just a passive
covering
4
Anatomy
Two layersbull Epidermisbull Dermis
5
Skin Functions
Sensation Protection Temperature regulation Fluid retention
6
Burn Pathophysiology
Loss of fluids Inability to maintain body
temperature Infection
7
Burn Pathophysiology
Patients with large burns (ge15 percent TBSA for young children and ge20 percent for older children and adolescents) develop systemic responses to these mediators
For patients with 40 percent TBSA or more myocardial depression can occur
As a result patients with major burns may become hypotensive (burn shock) and edematous (burn edema)
8
Burn PathophysiologyMetabolic response
Following resuscitation children with major burns develop a hypermetabolic response that results in a dramatic increase in energy expenditure and protein metabolism
Evidence suggests that modulation of the hypermetabolic response with therapies such as beta blockers and human growth hormone may improve outcomes for severely burned children
9
Pathophysiology
Systemic capillary leak usually persists for 18 to 24 hours Protein is lost from the intravascular space during the first 12 to 18 hours after a burn after which vascular integrity improves
10
Critical Factors
Depth Extent
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
3
Anatomy of Skin
Largest body organ More than just a passive
covering
4
Anatomy
Two layersbull Epidermisbull Dermis
5
Skin Functions
Sensation Protection Temperature regulation Fluid retention
6
Burn Pathophysiology
Loss of fluids Inability to maintain body
temperature Infection
7
Burn Pathophysiology
Patients with large burns (ge15 percent TBSA for young children and ge20 percent for older children and adolescents) develop systemic responses to these mediators
For patients with 40 percent TBSA or more myocardial depression can occur
As a result patients with major burns may become hypotensive (burn shock) and edematous (burn edema)
8
Burn PathophysiologyMetabolic response
Following resuscitation children with major burns develop a hypermetabolic response that results in a dramatic increase in energy expenditure and protein metabolism
Evidence suggests that modulation of the hypermetabolic response with therapies such as beta blockers and human growth hormone may improve outcomes for severely burned children
9
Pathophysiology
Systemic capillary leak usually persists for 18 to 24 hours Protein is lost from the intravascular space during the first 12 to 18 hours after a burn after which vascular integrity improves
10
Critical Factors
Depth Extent
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
4
Anatomy
Two layersbull Epidermisbull Dermis
5
Skin Functions
Sensation Protection Temperature regulation Fluid retention
6
Burn Pathophysiology
Loss of fluids Inability to maintain body
temperature Infection
7
Burn Pathophysiology
Patients with large burns (ge15 percent TBSA for young children and ge20 percent for older children and adolescents) develop systemic responses to these mediators
For patients with 40 percent TBSA or more myocardial depression can occur
As a result patients with major burns may become hypotensive (burn shock) and edematous (burn edema)
8
Burn PathophysiologyMetabolic response
Following resuscitation children with major burns develop a hypermetabolic response that results in a dramatic increase in energy expenditure and protein metabolism
Evidence suggests that modulation of the hypermetabolic response with therapies such as beta blockers and human growth hormone may improve outcomes for severely burned children
9
Pathophysiology
Systemic capillary leak usually persists for 18 to 24 hours Protein is lost from the intravascular space during the first 12 to 18 hours after a burn after which vascular integrity improves
10
Critical Factors
Depth Extent
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
5
Skin Functions
Sensation Protection Temperature regulation Fluid retention
6
Burn Pathophysiology
Loss of fluids Inability to maintain body
temperature Infection
7
Burn Pathophysiology
Patients with large burns (ge15 percent TBSA for young children and ge20 percent for older children and adolescents) develop systemic responses to these mediators
For patients with 40 percent TBSA or more myocardial depression can occur
As a result patients with major burns may become hypotensive (burn shock) and edematous (burn edema)
8
Burn PathophysiologyMetabolic response
Following resuscitation children with major burns develop a hypermetabolic response that results in a dramatic increase in energy expenditure and protein metabolism
Evidence suggests that modulation of the hypermetabolic response with therapies such as beta blockers and human growth hormone may improve outcomes for severely burned children
9
Pathophysiology
Systemic capillary leak usually persists for 18 to 24 hours Protein is lost from the intravascular space during the first 12 to 18 hours after a burn after which vascular integrity improves
10
Critical Factors
Depth Extent
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
6
Burn Pathophysiology
Loss of fluids Inability to maintain body
temperature Infection
7
Burn Pathophysiology
Patients with large burns (ge15 percent TBSA for young children and ge20 percent for older children and adolescents) develop systemic responses to these mediators
For patients with 40 percent TBSA or more myocardial depression can occur
As a result patients with major burns may become hypotensive (burn shock) and edematous (burn edema)
8
Burn PathophysiologyMetabolic response
Following resuscitation children with major burns develop a hypermetabolic response that results in a dramatic increase in energy expenditure and protein metabolism
Evidence suggests that modulation of the hypermetabolic response with therapies such as beta blockers and human growth hormone may improve outcomes for severely burned children
9
Pathophysiology
Systemic capillary leak usually persists for 18 to 24 hours Protein is lost from the intravascular space during the first 12 to 18 hours after a burn after which vascular integrity improves
10
Critical Factors
Depth Extent
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
7
Burn Pathophysiology
Patients with large burns (ge15 percent TBSA for young children and ge20 percent for older children and adolescents) develop systemic responses to these mediators
For patients with 40 percent TBSA or more myocardial depression can occur
As a result patients with major burns may become hypotensive (burn shock) and edematous (burn edema)
8
Burn PathophysiologyMetabolic response
Following resuscitation children with major burns develop a hypermetabolic response that results in a dramatic increase in energy expenditure and protein metabolism
Evidence suggests that modulation of the hypermetabolic response with therapies such as beta blockers and human growth hormone may improve outcomes for severely burned children
9
Pathophysiology
Systemic capillary leak usually persists for 18 to 24 hours Protein is lost from the intravascular space during the first 12 to 18 hours after a burn after which vascular integrity improves
10
Critical Factors
Depth Extent
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
8
Burn PathophysiologyMetabolic response
Following resuscitation children with major burns develop a hypermetabolic response that results in a dramatic increase in energy expenditure and protein metabolism
Evidence suggests that modulation of the hypermetabolic response with therapies such as beta blockers and human growth hormone may improve outcomes for severely burned children
9
Pathophysiology
Systemic capillary leak usually persists for 18 to 24 hours Protein is lost from the intravascular space during the first 12 to 18 hours after a burn after which vascular integrity improves
10
Critical Factors
Depth Extent
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
9
Pathophysiology
Systemic capillary leak usually persists for 18 to 24 hours Protein is lost from the intravascular space during the first 12 to 18 hours after a burn after which vascular integrity improves
10
Critical Factors
Depth Extent
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
10
Critical Factors
Depth Extent
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
11
Burn Depth
First Degree (Superficial)bull Involves only epidermisbull Redbull Painfulbull Tenderbull Blanches under pressurebull Possible swelling no blistersbull Heal in ~7 days
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
12
Burn Depth
Second Degree (Partial Thickness)bull Extends through
epidermis into dermisbull Salmon pinkbull Moist shinybull Painfulbull Blisters may be presentbull Heal in ~7 to 21 days
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
13
Burn Depth
Burns that blister are second degree
But all second degree burns donrsquot blister
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
14
Burn Depth
Third Degree (Full Thickness)bull Through epidermis dermis
into underlying structuresbull Thick drybull Pearly gray or charred blackbull May bleed from vessel
damagebull Painlessbull Require grafting
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
15
Burn Depth
Often cannot be accurately determined in acute stage
Infection may convert to higher degree
When in doubt over-estimate
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
16
Burn Extent
Pediatric Rule of Nines18
9 9
135135
1
18 Front18 Back
For each year over 1 year of age subtract 1 from headadd equally to legs
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
17
Burn Extent
Rule of Palmbull Patientrsquos palm
equals 1 of his body surface area
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
18
Burn Extent
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
19
Burn Severity
Based onbull Depthbull Extentbull Locationbull Causebull Patient Agebull Associated Factors
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
20
Critical Burns Need Burn centre American Burn Association
Age lt10 years with gt10 percent TBSA burn Age ge10 years with gt20 percent TBSA burn Full thickness burn gt5 percent TBSA Inhalational injury Any significant burn to face eyes ears genitalia
or joints Significant associated injuries (fractures or major
trauma)
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
21
Associated Factors
Patient Agebull lt 5 years oldbull gt 55 years old
Burn Locationbull Circumferential burns of chest
extremities
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
22
Burn shock
characterized by specific hemodynamic changes (decreased cardiac output and plasma volume increased extracellular fluid and oliguria)
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
23
Burn Edema
Fluid shift intravascular to extravascular soon after a burnmdashpersist for the first 24 hours
In small burns edema peaks early in large burns edema developed continue for 18-24 hours
Unburned tissue edema occurs when burn exceeds 35-40 TBSA
Early increase vascular permeabilitymdashin part related to histaminemdashmechanism is likely related to PMN and their adhesion to the endothelium
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
24
Burn Management
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
25
Stop Burning Process
Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn leave in place
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
26
Assess AirwayBreathing
Start oxygen ifbull Moderate or critical burnbull Decreased level of consciousnessbull Signs of respiratory involvementbull Burn occurred in closed spacebull History of CO or smoke exposure
Assist ventilations as needed
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
27
Assess Circulation
Check for shock signs symptoms
Early shock seldom results from effects of burn itself
Early shock = Another injury until proven otherwise
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
28
Obtain History
How long ago What has been done What caused burn Burned in closed space Loss of consciousness Allergiesmedications Past medical history
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
29
Rapid Physical Exam
Check for other injuries Rapidly estimate burned unburned
areas Remove constricting bands
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
30
Treat Burn Wound
Cover with DRY CLEAN SHEETS Do NOT rupture blisters Do NOT put goo on burn
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
31
Special Considerations
In Pediatrics always Consider possibility of abuse As many as 10 of abuse cases
involve burns
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
32
Burn Management
Parkland formula as follows (2-4 cm3 of crystalloid) X (
BSA burn) X (body weight in kg) The Parkland formula must be
modified in pediatric patients by adding maintenance
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
33
Burn Management Fluid resuscitation
Estimating fluid requirements for the first 24 hours following a burn injury include
Parkland - 4 mLkg per percent total burn surface area (TBSA) Add glucose maintenance fluid for children lt5 years of age
Galveston - 5000 mLm2 per percent TBSA Add 2000 mLm2 per day for maintenance requirements
Half of the fluid is given over the first 8 hours The remaining half is given over the next 16 hours
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
34
Burn Management Fluid resuscitation
Choice of fluid Ringers lactate (RL) is the resuscitation
and maintenance fluid of choice for the first 24 hours at most burn centers
Experts recommend adding D5 to maintenance fluid for children lt20 kg to prevent hypoglycemia
Colloid is typically added after 24 hours to restore oncotic pressure and preserve intravascular volume
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
35
Burn Management Colloid resuscitation
The addition of plasma or albumin to resuscitation fluids has been criticized on the assumption that the burn-induced increase in vascular permeability and the consequent extravasation of proteins persist for up to 36 h post injury
The main concern is that protein administration during the first 24 h increases protein accumulation in the interstitium and thus traps water
Using 131iodine-labeled albumin and autoradiographic techniques to demonstrate have shown that effective transcapillary sieving of albumin molecules into burned skin essentially stops at approximately 8 h post injury and that edema of injured tissues maximal at 3 h post burn persists beyond24 h post injury
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
36
Burn Management Fluid resuscitation
Monitoring fluid status The volume status of burn patients must be carefully
monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload The following parameters are helpful
Urine output should be maintained at 1 to 2 mLkg per hour for children lt30 kg and 05 to 1 mLkg per hour for those ge30 kg
Heart rate is a better monitor of circulatory status in children than is blood pressure Tachycardia may indicate hypovolemia but pain can elevate heart rate in euvolemic patients
Metabolic acidosis can be a marker for inadequate fluid resuscitation but also occurs with carbon monoxide or cyanide exposure
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
37
Burn Management Fluid resuscitation
Burn Children not response to large fluid volumes to maintain adequate perfusion
Volume loss from occult injuries Neurogenic shock as the result of a
spinal cord injury Myocardial depression or decreased
vascular tone from inhaled or ingested toxins
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
38
Burn Management Pain control
Most burn centers use morphine Fentanyl may be a safer choice for
initial pain management for patients whose cardiovascular status may be unstable
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
39
Burn Management Antibiotics
Topical antibiotics have been used to dress burn wounds
It is available and reduce the risk of infection
The topical antibiotic is applied to the wound which is then covered with a nonadherent dressing
Specific antibiotic Silver sulfadiazine Mafenide Bacitracin
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
40
Burn Management Special Considerations
Steroids have no role in treating burn wounds
Intravenous antibiotics are not recommended in the initial treatment of most burn patients as it may increase the chance of colonization with more virulent and resistant organisms They should be reserved for those patients with secondary infections
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
41
Burn Complications Infection
Early Infections Organism GAS S aureus Specific colonization of burn wounds is somewhat predictable
over time Initially gram-positive organisms are present infection that occurs in the first 48 hours after the burn is
usually secondary to GAS The incidence of GAS infections in burned patients has
decreased probably secondary to immediate use of topical antimicrobial therapy
Routine administration of antibiotics prophylaxis is not recommended ( colonization and potential infection with more resistant organisms)
S aureus also causes early septicemia If there is concomitant inhalation injury
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
42
Burn Complications Bacteremia
Bacteremia is not uncommon in the burned patient
Risk factors include wound manipulation and the presence of an intravascular catheter
infected intravascular thrombus can cause persistent bacteremia
Endocarditis must be considered in any patient with prolonged bacteremia
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
43
Burn Complications Renal failure
ARF in burn patients is not common Two distinct pictures
of ARF can be observed early ARF occurring either few hours after injury or in the first few days and late ARF developing approximately 1 or more weeks after burn injury Early ARF may be due to hypovolemia and hypoperfusion of the kidneys whereas late ARF is a consequence of infection
endotoxemia and MODS
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
44
Burn Complications Renal failure
Renal damage can arise even from hemoglobinuria
in burn patients with associated hemolysis the administration of haptoglobin may prevent hemoglobinuria-nduced renal failure
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
45
Inhalation Injury
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
46
Inhalation Injury
10-20 hospitalized burn patients sustained inhalation injury
Increased mortality History (closed space) PE (facial burn singed nasal hairs erythema
carbonaceous material in back of the troat) laboratory tests (carboxyhemoglobingt15) and
bronchoscopy (erythema and sooty deposite in the airway)
Treatment supportive Nasotracheal or endotracheal intubation preferable to early tracheostomy Prophylactic antibiotics and steroids not indicated
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
47
Inhalation Injury Problems
Hypoxia Carbon monoxide toxicity Upper airway burn Lower airway burn
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
48
Inhalation Injury Carbon Monoxide
Product of incomplete combustion Colorless odorless tasteless Binds to hemoglobin 200x stronger
than oxygen Headache nausea vomiting
ldquoroaringrdquo in ears
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
49
Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
50
Inhalation Injury Carbon Monoxide
Measurement Carbon monoxide has various effects depending upon
levels
Must check levels on Blood Gas analysis 10487081048708 0-10 can be seen in smokers can be seen in
smokers 10487081048708 10-20 patients can have headache 10487081048708 20-30 patients develop severe headache
nausea vomiting CNS collapse 10487081048708 30-40 patients present with syncope
convulsions depressed cardiac activity and respiratory function
10487081048708 40 and greater death may ensue within hours
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
51
Inhalation Injury Upper Airway Burn
True Thermal Burn Danger Signs
bull Neck face burnsbull Singing of nasal hairs eyebrowsbull Tachypnea hoarseness droolingbull Red dry oralnasal mucosa
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
52
Inhalation Injury Lower Airway Burn
Danger Signsbull Loss of consciousnessbull Burned in a closed spacebull Tachypnea (+-)bull Coughbull Rales wheezes rhonchibull Carbonaceous sputim
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
53
Electrical Burns
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
54
Electrical Burns Considerations
Intensity of current Duration of contact Kind of current (AC or DC) Width of current path Types of tissues exposed
(resistance)
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
55
Electrical Burns Considerations
Conductive injuriesbull ldquoTip of Icebergrdquobull Entranceexit wounds may be smallbull Massive tissue damage between
entranceexit
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
56
Electrical Burns Management
Make sure current is off Check ABCs Assess carefully for other injuries Patient needs hospital evaluation
observation
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
57
Electrical Injury Complications
If gross urinary pigment is present sodium bicarbonate and mannitol are initially given in addition to Ringerrsquos lactate
Diuretics in contraindicated Urine output maintained 100-125 mlh until it
is seen to clear Precipitate cardiac arrhythmiaroutine cardiac
monitoring not necessary unless cardiac arrest at accident abnormal EKG arrhythmia during transport
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
58
Electrical InjuryOther Complications
Respiratory arrest Spinal fractures Long bone fractures
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
59
Chemical Burns
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
60
Chemical Burns
Alkaline substances such as sodium and potassium hydroxides and cements are most common cause of chemical burn
Direct chemical reaction instead of heat production
Often underestimated Immediate treatmentmdashcopious tap water lavaging
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
61
Chemical Burns Concerns
Damage to skin Absorption of chemical systemic
toxic effects Avoiding EMS personnel exposure
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
62
Chemical Burns Management
Remove chemical from skin Liquids
bull Flush with water Dry chemicals
bull Brush awaybull Flush what remains with water
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
63
Chemical BurnsInjuries require special care
Hydrofluoric acid treated with a paste made of 35 ml of 10 calcium gluconate in 150 gm of K-Y jelly Applied to the affected area and changed every hour if needed More severe case require subcutaneous injection of calcium
gluconate into the painful area
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
64
Chemical BurnsInjuries require special care
Phenol not soluble in water Absorbed through intact skin Topical application of polyethylene glycol or vegetable oil
Phosphorus keep the areas copiously irrigated and continuously wet with water early debridement of extraneous particles
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
65
Chemical BurnsInjuries require special care
Cement rinsed with water until the soapy feeling disappear then dried thoroughly
Tar respond well to application of bacitracin or neomycin ointment for 12 hours then washed off and silver sulfadiazine applied
66
Thank You
66
Thank You
