Pre-Hospital Burn Management Part 1: The Basics

1. Pre-Hospital Burn Management Part 1: The Basics Robert S. Cole Paramedic, CCEMT-P

5. For this class I referenced text from:

6. Advanced Burn Care in the Field It is difficult to go over the aspects of burn care in a mere hour, ABLS takes 16 hours for its burn course. For a more detailed and in complete look, taking the ABLS class is highly recommended. This lecture will try to hit on some hopefully new and exciting material to �Take home � with you while still doing justice to the basics..

7. Objectives Understand the basic anatomy and function of the skin Identify the types of common burn trauma Accurately assess the burn severity, and common progression of patient condition Identify co morbid factors

8. The Basics A Review

9. The Skin Largest Organ in the human Body Sensory Temperature Regulation Barrier vs. Infection and Fluid loss Identification and form

10. The Skin Three Basic Layers The Epidermis : 3 sublayers. The stratum corneum , the squamous layer , and the basal layer , these are the outer layers, providing protection and pigment. The Dermis: The Layer that contains blood vessels, lymph vessels, Hair follicles, and sweat glands, all held together by COLLIGEN. The subcutaneous layer, AKA the subcutis, forms a network of collagen and fat cells. The subcutis is responsible for conserving the body's heat, while helping to protect the organs of the body from injury by acting as a "shock-absorber".

11. The Skin

12. Types of burns Thermal (Flame, Steam, scalds, sunburn, etc.) Chemical (Lye, Hydrofluoric Acid) Electrical Radiological

13. Assessing the Burns Primary Goal is to assist with the rapid evaluation of severity of the burns and to facilitate transfer to a burn center if needed. Secondary goal is to give all providers a common ground and language when discussing these burns. Rule of 9�s, ABA Criteria

14. Assessing the Burns Most field providers and non burn specialist often UNDERESTIMATE BSA of burn. In reality even after the primary burning process stops, heat retention in the body continues to damage the tissue. True extent of burns may not be evident for several hours. It is more important to get an initial working idea on SEVERITY of the Pt as a whole, not just focusing on BSA, Consider ALL factors.

15. Assessing the Burns The Rule of 9�s for BSA (Simi Complex, Simi Accurate, widely used) Lund and Browder method (complex, accurate) ABA classification for severity (Considers whole picture) The traditional classification of burns as first, second or third degree is being replaced by the designations of superficial , superficial partial thickness , deep partial thickness and full thickness .

16. The Rule of 9�s

17. ABA Grading System: Minor Burns <10 percent TBSA burn in adult 5 percent TBSA burn in young or old <2 percent full-thickness burn

18. ABA Grading System: Moderate Burns 10 to 20 percent TBSA burn in adult 5 to 10 percent TBSA burn in young or old 2 to 5 percent full-thickness burn High-voltage injury, suspected inhalation injury,circumferential burn Concomitant medical problem predisposing the patient to infection (e.g., diabetes, sickle cell disease) Minimum Care: Hospital admission

19. ABA Grading System: Major Burns >20 percent TBSA burn in adult >10 percent TBSA burn in young or old >5 percent full-thickness burn High-voltage burn Known inhalation injury Any significant burn to face, eyes, ears, genitalia or joints circumferential burn w/ compromise Significant associated injuries (e.g. fracture, other major trauma)

20. Assessing the Burns 1st degree or superficial Burn Painful, Red Dry Blanch with pressure Sunburn, low intensity flash burn Pain is the major issue to deal with

21. 1st degree/superficial

22. Assessing the Burns Second Degree Burns, AKA: Partial Thickness (Deep vs. Superficial) Typically painful unless nerve endings are damaged Blisters, High Intensity Flash Burns, Hot Grease, Steam and Flame Infection, swelling, and Pain are primary initial concerns. Dehydration may develop over time with large BSA.

23. 2nd Degree, Superficial Partial Thickness

24. 2nd Degree, Deep Partial Thickness

25. Assessing the Burns 3rd degree, AKA Full Thickness May be white and waxen or may be charred (Eschar). No sensation is typical, Cap refill is absent Primary concerns are infection, pain control and severe swelling

26. Assessing the Burns A common Misconception is that 3rd degree Burns are painless. In reality while 3rd degree burns may be insensate the burns are usually surrounded by a Halo of severe and very painful 2nd degree burned tissue, known as the �Zone of Stasis� This is further complicated by the swelling that develops with 2nd and 3rd degree burns causing further pain .

27. 3rd degree , Full thickness

28. Assessing the Burns� 4th Degree or �Bone Burns� Classification occasionally used in some texts Used to describe the massive destruction of tissue to effected areas Often appears �To the Bone�

29. Complicating Factors

30. Complicating or Co-Morbid Factors Associated Trauma Inhalation Injuries Circumferential Burns Electricity Age (Young or Old) Pre-Existing Disease Abuse

31. Associated Trauma Spinal Injuries Airway Trauma Chest Trauma/Baro Trauma Abd. Trauma CHI Open wounds/Fractures/Shrapnel Shock If you find a Hypotensive acute burn Patient, there is something else you are missing!

32. Inhalation Injuries

33. Inhalation Injuries Three basic Types of inhalation Injury CO Poisoning Injury above the Glottis Injury Below the glottis Onset of S/S of inhalation injury in unpredictable enough that these patients should be generally be observed for 24 hours.

34. Inhalation Injuries Most fatalities reported at fires are secondary to inhalation injuries CO Binds to Hemoglobin with approx. 100 times stronger bond than does O2 Carboxyhemoglobin levels are found in excess of 50-70% in such patients. Levels of 40-60% may cause mental status changes

35. Inhalation Injuries Except for rare events, thermal inhalation injuries are limited to the upper airways When damage does occur, it is often severe enough to cause airway obstructions. This may occur at any time during the resuscitation In the case of hypotension/hypovolemia, the onset of edema may be delayed until perfusion is restored.

36. Inhalation Injuries Warning signs can be subtle. Suspicions based on: Hx of event Mental Status Voice Lung sounds Assessment findings Pediatrics are especially high risk secondary to their small airways. Hx of event: enclosed space Decreasing or obtunded mental status Coughing Chest pain Expiratory wheezes.Hx of event: enclosed space Decreasing or obtunded mental status Coughing Chest pain Expiratory wheezes.

37. Inhalation Injuries Early treatment includes high flow O2, Humidified if possible Liberal use of Nasal ETT or RSI and oral ETT placement early in the care plan Aggressive pain control Hyperbaric Chambers are of unproven value.

38. Circumferential Burns Circumferential Burns, or near circumferential burns, especially predominately 3rd degree burns, cause swelling to underlying tissues This swelling impairs respiration, circulation and function. This can cause permanent complications and death.

39. Circumferential Burns Of Main concern are circumferential burns to the chest. As swelling increases the mechanics of respiration are impaired, the patient will become even more hypoxic and die. This is even more rapid in children who have poor respiratory reserves.

40. Circumferential Burns Treatment is an Emergent Pre-Hospital Escharotomy This should be done after Pneumothorax, ETT/D.O.P. E. , and other issues are considered, however the progression to this treatment should be rapid.

41. Electricity Safety is first. Go home at the end of your shift. Electrical burns can cause a path of destruction from entrance and exit wounds that may not be readily apparent. Cardiac, Renal, and Electrolyte problems are major concerns. ALS observation is advised. arrhythmias include VT, VF Imbalances include Hyper K Tx per ACLS arrhythmias include VT, VF Imbalances include Hyper K Tx per ACLS

42. Electricity With lightning strikes, pt.�s who are in cardiac arrest are frequently revivable. The heart usually spontaneously converts from asystole/VF back to a perfusing rhythm, but it may take some time for the respiratory drives to recover

44. Chemical Burns May cause problems unrelated to the burns (Hydrofluoric Acid) May be difficult to stop the burning process (Chlorine Gas=Hydrochloric Acid) May have to chose between the lesser of two evils (Rapid decon vs. Treatment, Bicarb nebs, etc)

45. Age (Very Old or Young) The very old (>55) and the Young (<12) Pt�s less than 2 have an immature immune system Patients less than 12 have poor respiratory reserves Older patients have degenerative processes that lead to prolonged recover, not accounting for other medical problems All skin can be presumed to be thin in children younger than five years and in adults older than 55 years. It is best to assume that there are no superficial partial thickness burns in these age groups

46. Pre-Existing Disease Renal Failure: Even Patients that do not have acute renal failure, but may have risk factor for such, may be thrown into renal failure either by the burn process or by the Hypoperfusion state that develops Hyper K is a risk as well (after 36 hours) Diabetes Cardiac Problems Respiratory problems

47. Abuse/Intentional Burns May be young, Old , or the disabled. May be domestic in nature. Suspected abuse patients should be transported when ever possible Document thoroughly but objectively Do not press to hard , the important thing is to get the patient to the hospital, be careful not to prompt a �refusal� Be aware of psychological issues and act accordingly Be aware that some of these injuries may be cultural in nature (cupping, coining)

48. Abuse/Intentional Burns burns scalding (most common burn injury) range from first to third degree in severity usually include splash burns accidental burns from hot, liquid spills usually more severe on upper body than lower body because liquid cools while flowing down - occur usually on front of body

49. Abuse/Intentional Burns be suspicious - scald burns on back well defined, uniform 2nd-3rd degree burns on buttocks, extremities immersion burns inflicted maybe as punishment for toileting mishaps may be seen on buttocks on extremities - stocking or glove appearance where feet, hand dipped into hot water

50. Abuse/Intentional Burns imprint burns caused by hot object held to skin - like cigarette or curling iron child usually moves away from hot object before receiving serious burns (accidental burn will usually be a single linear mark instead of full imprint which leaves outline - usually found on palm of hand where child grasps hot object) be suspicious - burns on back of hand cigarette burns usually 5-7 mm in diameter, well defined, deep puncture lesion under cigarette burn scab

51. Other injuries treated as burns: Bed sores Frost Bite Gangrene

52. Referral Criteria 2nd or 3rd Degree Burns >10% BSA Burns to Face, Hands , Feet, Genitailia, Perineum, or major Joints. ESPECIALY CIRCUMFRENTIAL BURNS Electrical Burns Chemical Burns Inhalation Injury

53. Referral Criteria Burns with pre-existing PMHX that could complicate recovery Concomitant trauma (If Major Trauma, The Trauma Center , Not the Burn Center should be the initial stabilizing unit) When in doubt , consult with a burn center

54. Questions?