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Chapter 21 Burns

Chapter 21 Burns. Topics. Introduction to Burn Injuries Pathophysiology of Burns Assessment of Thermal Burns Management of Thermal Burns Assessment and Management of Electrical, Chemical, and Radiation Burns. Introduction to Burn Injuries.

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Chapter 21 Burns

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  1. Chapter 21Burns

  2. Topics • Introduction to Burn Injuries • Pathophysiology of Burns • Assessment of Thermal Burns • Management of Thermal Burns • Assessment and Management of Electrical, Chemical, and Radiation Burns

  3. Introduction to Burn Injuries • 1.25-2 million Americans treated for burns annually • 50,000 require hospitalization • 3-5% considered life threatening • 2nd leading cause of death for children <12 • Half of all tap-water burns occur to children <5 • Greatest risk • Very young & very old • Infirm • Firefighters • Metal smelters • Chemical workers

  4. Pathophysiology of Burns • Types of Burns • Thermal (heat) • Electrical • Chemical • Radiation

  5. Thermal Burns • Heat changes the molecular structure of tissue • Denaturing (of proteins) • Extent of burn damage depends on • Temperature of agent • Concentration of heat • Duration of contact

  6. Epidermis Dermis Subcutaneous Tissue Functions of the Skin • Skin is the largest organ. • Functions: • Mechanical barrier • Protective barrier • Sensory organ • Temperature regulation

  7. Thermal Burns • Jackson’s Theory of Thermal Wounds • Zone of Coagulation • Area in a burn nearest the heat source that suffers the most damage as evidenced by clotted blood and thrombosed blood vessels • Zone of Stasis • Area surrounding zone of coagulation characterized by decreased blood flow. • Zone of Hyperemia • Peripheral area around burn that has an increased blood flow.

  8. Jackson’s Theory of Thermal Wounds Zone of Hyperemia Zone of Stasis Zone of Coagulation

  9. Body’s Response to Burns • Emergent Phase (Stage 1) • Happens immediately • Pain response • Catecholamine release • Tachycardia, Tachypnea, Mild Hypertension, Mild Anxiety • Fluid Shift Phase (Stage 2) • Length 18-24 hours • Begins after Emergent Phase • Reaches peak in 6-8 hours • Damaged cells initiate inflammatory response • Increased blood flow to cells • Shift of fluid from intravascular to extravascular space • MASSIVE EDEMA • “Leaky Capillaries

  10. Body’s Response to Burns • Hypermetabolic Phase (Stage 3) • Last for days to weeks • Large increase in the body’s need for nutrients as it repairs itself • Resolution Phase (Stage 4) • Scar formation • General rehabilitation and progression to normal function

  11. Courtesy of Bonnie Meneely, EMT- P Courtesy of David Effron, M.D. Electrical Burns

  12. Electrical Burns • Terminology • Voltage • Difference of electrical potential between two points • Different concentrations of electrons • Amperes • Strength of electrical current • Resistance (Ohms) • Opposition to electrical flow

  13. Electrical Burns • Ohm’s Law V: Voltage R: Resistance I: Current • Based on electron flow thru Tungsten • Emit more light the more current passed through

  14. Electrical Burns • Joule’s Law P: Power I: Current R: Resistance • Skin is resistant to electrical flow

  15. Electrical Burns • Greatest heat occurs at the points of higher resistance • Entrance and Exit wounds • Dry skin = Greater resistance • Wet Skin = Less resistance • Longer the contact, the greater the potential of injury • Increased damage inside body • Smaller the point of contact, the more concentrated the energy, the greater the injury

  16. Electrical Burns • Electrical Current Flow • Tissue of Less Resistance • Blood vessels • Nerve • Tissue of Greater Resistance • Muscle • Bone • Results in: • Serious vascular and nervous injury • Immobilization of muscles • Flash burns

  17. ACID BURN Chemical Burns

  18. Chemical Burns • Chemical destroys tissue • Acids • Form a thick, insoluble mass where they contact tissue. • Coagulation necrosis • Limits burn damage • Alkalis • No protective coagulum • Destroys cell membrane through liquefaction necrosis • Deeper tissue penetration and deeper burns

  19. Radiation Injury • Radiation • Transmission of energy • Nuclear Energy • Ultraviolet light • Visible Light • Heat • Sound • X-Rays • Radioactive Substance • Emits ionizing radiation • Radionuclide or Radioisotope

  20. Radiation InjuryBasic Physics • Protons • Positive charged particles • Neutrons • Equal in mass to protons • No electrical charge • Electrons • Minute electrically charged particles • When emitted from radioactive substances are termed Beta Particles (continued)

  21. Radiation InjuryBasic Physics • Isotopes • Atoms with unstable nuclear composition • Ionizing Radiation • Half-life • Time required for half the nuclei to lose activity through decay

  22. Radiation InjuryRadioactive Substances • Alpha Particles • Slow moving • Low-energy • Stopped by clothing and paper • Penetrate a few cell layers on skin • Minor external hazard • HARMFUL if ingested • Beta Particles • Smaller than Alpha • Higher energy than alpha • Stopped by aluminum or similar materials • Less local damage than alpha • HARMFUL if inhaled or ingested

  23. Radiation InjuryRadioactive Substances • Gamma Rays • Highly energized • Penetrate deeper than Alpha or Beta • EXTREMELY DANGEROUS • Penetrate thick shielding • Pass entirely thru clothing, and body • Extensive cell damage • Indirect Damage • Cause internal tissue to emit Alpha and Beta particles • LEAD SHIELDING • Neutrons • Most Penetrating than other radiation • 3-10 times greater penetration than Gamma • Less internal hazard when ingested than Alpha or Beta • Direct tissue damage • Only present in Nuclear Reactor Core

  24. Factors AffectingExposure to Radiation • Duration of exposure • Distance from the source • Shielding from the source

  25. Radiation Effects on Body • Alters body’s cell DNA • Cumulative damage over lifetime exposure • Decreased WBC’s • Acute Effects • minutes-weeks • Long-Term Effects • Effects years or decades later • Geiger Counter needed to detect • R/hr: Milliroentgens per hour • 1,000mR = 1R • RAD • ‘Radiation Absorbed Dose’ of local tissue • REM • Roentgen equivalent in man • Injury to irradiated part of organism • RAD=REM for all purposes

  26. Radiation Injury: Safety TIME • Clean Accident • Exposed to radiation • Not contaminated by products • Properly decontaminated • Little danger to personnel • Dirty Accident • Assoc with Fire at scene of radiation. Accident • Trained Decontamination Personnel DISTANCE SHEILDING

  27. Radiation InjuryManagement • Refer to BLS standards • Park upwind and uphill • Notify Police, Fire & Haz-Mat • Identify radioactive material • Decontaminate patients before care • Routine medical care (ABC’s, etc)

  28. Inhalation Injury • Toxic Inhalation • Synthetic resin and plastic combustion • Produces Cyanide & Hydrogen Sulfide • Systemic poisoning • More frequent than thermal inhalation burn • Affects can be immediate or delayed • Carbon Monoxide Poisoning • Colorless, odorless, tasteless gas • Byproduct of incomplete combustion of carbon products • Suspect with faulty heating unit • 200x greater affinity for hemoglobin than oxygen • Hypoxemia & Hypercarbia

  29. Inhalation Injury • Airway Thermal Burn • Supraglottic structures absorb heat and prevent lower airway burns • Moist mucosa lining insulates and absorbs heat • Superheated steam can injury lower airway • Risk Factors • Standing in the burn environment • Screaming or yelling in the burn environment • Trapped in a closed burn environment • Symptoms • Stridor or “Crowing” inspiratory sounds • Singed facial and nasal hair • Black sputum or facial burns • Progressive respiratory obstruction and arrest due to swelling

  30. Depth of Burn • Superficial Burn • Partial Thickness Burn • Full Thickness Burn

  31. Burn Depth • Superficial Burn:1st Degree Burn • Signs & Symptoms • Reddened skin • Pain at burn site • Involves only epidermis

  32. Burn Depth • Partial-Thickness Burn: 2nd Degree Burn • Signs & Symptoms • Intense pain • White to red skin • Blisters • Involves epidermis & dermis

  33. First Degree Burn Second Degree Burn Partial-Thickness Burns1st & 2nd Degree

  34. Burn Depth • Full-Thickness Burn: 3rd Degree Burn • Signs & Symptoms • Dry, leathery skin (white, dark brown, or charred) • Loss of sensation (little pain) • All dermal layers/tissue may be involved

  35. Full-thickness Eschar Partial- thickness Full-Thickness Burns3rd Degree

  36. Body Surface Area • Rule of Nines • Best used for large surface areas • Expedient tool to measure extent of burn • Rule of Palms • Best used for burns < 10% BSA

  37. Rules of Nines

  38. Rule of Palms • A burn equivalent to the size of the patient’s hand is equal to 1% body surface area (BSA)

  39. Systemic Complications • Hypothermia • Disruption of skin and its ability to thermoregulate • Hypovolemia • Shift in proteins, fluids, and electrolytes to the burned tissue • Loss of osmotic pressure • General electrolyte imbalance • Eschar • Hard, leathery product of a deep full thickness burn • Dead and denatured skin constricts over the wound  Increased pressure from edema and restricts blood flow

  40. Systemic Complications • Infection • Greatest risk of burn is infection • Organ Failure • Kidneys • Liver • Heart • Special Factors • Age & Health • Physical Abuse • Elderly, Infirm or Young

  41. Assessment of Thermal Burns • Scene Size-up • Fire Department • SCBA and protective clothing • Stop any continued burning on the patient • MOI • Primary Assessment • ABC’s MUST be intact • Rapid transport for any airway burns • Rapid evacuation of patient if scene is unstable

  42. Assessment of Thermal Burns • Head/Neck, Chest, Abdomen, Pelvis, Extremities • Accurately approximate extent of burn injury • Rule of Nines or Rule of Palms • Depth of burn • Area of body effected • Any burn to the face, hands, feet, joints or genitalia is considered a serious burn • “Ringing” burns • Age of patient affected, current illnesses

  43. Assessment of Thermal BurnsGeneral Signs & Symptoms • Pain • Changes in skin condition at affected site • Adventitious sounds • Blisters • Sloughing of skin • Hoarseness • Dysphagia • Dysphasia • Burnt hair • Edema • Paresthesia • Hemorrhage • Other soft tissue injury • Musculoskeletal injury • Dyspnea • Chest pain

  44. Assessment of Thermal Burns Burn Severity Minor Superficial <50% BSA Partial Thickness <15% BSA Full Thickness <2% BSA Moderate Superficial >50% BSA Partial Thickness >15% BSA Full Thickness >2% BSA Critical Partial Thickness >30% BSA Full Thickness >10% BSA Inhalation Injury Any partial or full thickness burn involving hands, feet, joints, face, or genitalia

  45. Assessment of Thermal Burns • Burns to the face, hands, feet, joints, genitalia, and circumferential burns are of special concern. • Ongoing Assessment • Non-critical: Reassess Q 15 min • Critical: Reassess Q 5 min • Burn Center Care

  46. Management of Thermal Burns • Local & Minor Burns • Local cooling • Partial thickness: <15% of BSA • Full thickness: <2% BSA • Remove clothing • Comfort and Support • Consider analgesics

  47. Management of Thermal BurnsModerate to Severe Burns • Sterile dressings • Wet vs Dry dressings • Partial thickness: >15% BSA • Full thickness: >5% BSA • Burn surfaces contacting each other • Maintain warmth • Prevent hypothermia • Consider aggressive fluid therapy • Moderate to severe burns • Burns over IV sites • Place IV in partial thickness burn site.

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