Burn Management

1. PCP - GORD PATTERSON, ALS-A//V , ACP Burn Management

2. Paramedic Burn Care • Primary Care Paramedics: • a critical link allowing serious Burns to achieve maximally favourable outcomes

3. Burns must grab your attention • You will be faced with this sometime in your career

4. Visual appearance of injury can create anxiety and scene management challenges

5. Goal Today is to prepare you to manage burns • To reinforce an understanding of the anatomy and the pathophysiology of burn dynamics. • To enable the student to assess burn characteristics to thereby provide appropriate care to the burn victim.

6. Focus on thermal burns • Burns described • Skin anatomy and function • Respiratory considerations • Fluid shifting • Burn Depth and Zones • Burn Severity • Size estimations • PCP management considerations • Dressing considerations & characteristics

7. Format – 2.5 hours • Introduction • P/P Presentation • Break out group Burn Classification • Group discussion • P/P Presentation • Break out group Burn size estimation • Group discussion • P/P Presentation • Summary

8. Fast Facts • Burns are common • Create complex medical challenges • Can be disfiguring and disabling • 2nd leading cause of accidental death in Canada ~ 412 yearly. ~ 40 are children (Fire Prevention Canada)

9. Serious medical issue • ~ 73% of deaths are from fires in the home • Scalding by liquids is the leading cause of pediatric burn injuries • 2,000,000 treatments yearly in Canada and USA

10. Burns described • A burn is an injury to tissues caused by heat, flame, chemicals, radiation, friction. Burns are classified as • Thermal • Chemical • Electrical • Radiation

11. Burns characteristics defined by : • Mechanism of injury • Depth of tissue damage • Severity of injury to the patient • Total body surface involved

12. Injury mechanisms are further grouped • Scalds • Contact Burns • Fire • Chemical • Electrical • Radiation

13. Review of skin A & P • Skin is the largest organ of the body • Surface area is approx 1.8 m2 in adults and .025 m2 in children • It is the most exposed body organ and prone to burns • It makes up 12 – 15% of body mass

14. Skin Function Summary • Provides protection against infection • Retains body fluids • Sensory organ and information gatherer • Assists in maintaining body temperature • Protects internal organs • Vitamin D production • Expressive communication

15. Skin Layers • Epidermis – thinnest layer • Tough protective barrier • Protects internal organs • Sensory aid • Dermis • Contains blood vessels, nerve endings • Prevents water loss (evaporation) • Prevents heat loss • Hypodermis • Subcutaneous tissue primarily fat, connective tissue, and vascular structure

16. Skin – Rich in vascular structures

17. Burns damage vascular structure creating capillary permeability & fluid shifting

18. Imagine this over 30% TBSA Picture source emedicine.com

19. Fluid shifting occurs in two stages • Hypovolemic stage ( onset to ~ 36-48 hours) • Diuretic stage ( ~ 48 - 72 hours after injury)

20. Hypovolemic Stage • Rapid fluid shifts - from the vascular compartments into the interstitial spaces • Capillary permeability increases with vasodilation, cell damage, and histamine release • Fluid loss deep in wounds • -Initially Sodium and H2O • -Protein loss - hypoproteninemia • Hemoconcentration - Hct increases • Low blood volume, oliguria • Hyponatremia - loss of sodium with fluid • Hyperkalemia - damaged cells release K, oliguria • Metabolic acidosis

21. Diuretic Stage • Capillary membrane integrity returns • Edema fluid shifts back into vessels - blood volume increases • Increase in renal blood flow - result in diuresis (unless renal damage) • Hemodilution - low Hct, decreased potassium as it moves back into the cell or is excreted in urine with the diuresis • Fluid overload can occur due to increased intravascular volume • Metabolic acidosis - HCO3 loss in urine, increase in fat metabolism

22. Respiratory System The airway epithelium are susceptible to injury from inhaled hot gases and can be life threatening • Mucous membranes of the nose, mouth, and oropharynx • Epiglottis, glottis and vocal cords • Epithelium of the lower respiratory track Air Flow Obstruction – hypoxia & Hypercarbia Burn gas by-product such as Carbon Monoxide can displace oxygen creating hypoxia

23. Continually monitor pulmonary status • Airway burns account for the majority of immediate and delayed deaths from burns (death up to 24 hours from injury)

24. Signs of a Respiratory Burn • Red Flags • History of a Closed area heat insult • Productive cough • Dyspnea • Facial burns • Singed nasal hair • Sooty sputum • Horse voice

25. Primary care of any burns begins with: • Classification of burn depth • Estimation of burn size

26. Classification of burn depth is determined by structures injured Increasing severity

27. Traditional Classification • 1st degree • Epiderminal layer, red, painful • 2nd degree • Epiderminal layer and some dermis, blisters, painful • 3rd degree • Full thickness epidermis, all dermis including hypodermis • 4th degree • Full thickness including hypodermis and deep facia

28. New Classification • Superficial • Superficial Partial Thickness • Deep Partial Thickness • Full Thickness • Fourth Degree

29. Superficial Burns • Involve only the epidermal layer of skin. • Red • Dry • Painful • Blanches • Heals spontaneously

30. Superficial

31. Superficial Partial Thickness • Involve entire epidermis and superficial portions of the dermis • Painful , red and weeping usually from blisters • Blanches with pressure • Generally heals spontaneously

32. Superficial Partial Thickness

33. Deep Partial Thickness • Involve entire epidermis • Extends into deeper dermis damaging glandular tissue and hair follicles • Blisters • Wet or waxy dry • Variable colour from patchy white to red • May heal spontaneously

34. Deep Partial Thickness

35. Full Thickness Burns • Includes destruction of epidermis, the entire dermis • Damage to the hypodermis • Waxy white to leathery grey to charred and black • Less painful • May require skin grafting

36. Full Thickness Burn

37. Fourth Degree Burns • Includes destruction of epidermis, the entire dermis and the hypodermis • Destruction of the hypodermis • Deep facia, variable colour, leathery, bone exposure • Less painful • Requires skin grafting

38. Fourth degree burn

39. Break Out Group Pictures • Four Groups • 15 minutes • Choose speaker to discuss burn Object: • Assess Burn Depth • Burn classification • Distinguishing features • Skin structures involved

40. Notions • Burns are generally have a combination of varying degrees and zones of burn classification in the same injury • All burns are painful • All victims are frightened • Burns have a “Wow Factor” and an unforgettable aroma

41. A single burn can be made up of combination of classifications

42. Cell damages occurs in varying degrees creating Burn Zones

43. Identify tissue viability

44. Critical burn body areas are: • Respiratory tract • Face, eyes • Hands & feet joint areas • Perineum • Circumferential burns

45. Circumferential burns constrict circulation

46. How does this occur • Encircling damaged skin (eschar) looses elasticity and constricts damaged tissues by compartmentalizing fluid shifting in underlying tissues increasing interstitial pressures that compress vascular structures and nerves • Tissue hypoxia • Further tissue & cell damage • Fixes: Escharotomy or Fasiotomy

47. Is this patient sick?

48. Severity of injury is dependent on • Size of burn or Total Body Surface Area injured (TBSA) • Classification or depth of injury • Critical area involvement • Age • Prior health status • Location of burn • Associated injuries

49. Accurate burn size estimation is essential to determine severity • Rule of Nines • Palmer Method • The area of the patient’s hand size including the fingers is approximately 1% TBSA

50. Rule of Nines