1、BURNS,Leaugeay Webre BS, CCEMT-P, NREMT-P,Scenario,Paramedic is called to the scene of a structure fire. FD has removed a victim from the house. BSI Scene safe 1 patient A/C standby FD/ PD on scene Now what?,General Impression,33 yo male pt writhing in pain. Screams and begs for pain medication howe
2、ver poor historian. S- blistering to back and chest, R upper ventral area leg exposed muscle; eyebrows singed A- PCN, codeine M- none P- none L- earlier today E- woke up on fire,A- B- C- Transport decision? % BSA burned? Tx?,Objectives,Describe the structure and function of skin Discuss the types of
3、 burns. Explain the degrees of thermal burns. Discuss causes and treatments of inhalation injuries. Identify methods of approximating burn injuries. Describe and apply treatment modalities for the burn patient.,Burns, thermal. Escharotomy to release chest wall and allow for ventilation of the patien
4、t.,Skin,Largest organ of the body,Anatomy,Epidermis Dermis Subcutaneous tissue,Layers Epidermis Dermis Subcutaneos Underlying Structures Fascia Nerves Tendons Ligaments Muscles Organs,Anatomy & Physiology of the Skin,Function,Protection Regulation Prevention Sensory,Epidermis,Outer, thinner layer Co
5、nsists of dead keratinized cells Protects dehydrationtraumalightinfection,Dermis,Gel like matrix Consists of collagen and elastin Contains blood vessels, lymphatics, sweat glands, hair follicles, sensory fibers,Subcutaneous,Connective tissue Adipose tissuecushioninginsulation,Causes,Thermal Electric
6、al Chemical Radiation,Thermal,Majorityflamescaldcontact with hot objects,Child with burns from a scald,Determining Severity,1st degree 2nd degree 3rd degree (4th degree),Depth of Burn,Superficial Burn Partial Thickness Burn Full Thickness Burn,First Degree,Superficial involve only epidermis Local pa
7、in and redness No blistering present Heal spontaneously 2-5 days without scarring Not included when calculating % TBSA,Burn Depth,Superficial Burn: 1st Degree Burn Signs & Symptoms Reddened skin Pain at burn site Involves only epidermis,Second Degree,Involve epidermis and dermis Partial thicknesssup
8、erficial partial thicknessred, painful, blistereddeep partial thicknesspale, mottled Very painful Infection may evolve into 3rd degree,Burn Depth,Partial-Thickness Burn: 2nd Degree Burn Signs & Symptoms Intense pain White to red skin Blisters Involves epidermis & dermis,Third Degree,Involve epidermi
9、s, dermis, subcutaneous tissue White, waxy, red, brown, leathery Dry and painless (muscle and bone),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,Fourth Degr
10、ee,Include involvement of muscle and bone Charred in appearance Painless,Pathophysiology,Local changes- 111F produce injury,Area of Damage,Zone of coagulation Zone of stasis Zone of hyperemia,Jacksons Theory of Thermal Wounds Zone of Coagulation Area in a burn nearest the heat source that suffers th
11、e 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.,Jacksons Theory of Thermal Wounds,Zone of Hyperemia,Zone
12、 of Stasis,Zone of Coagulation,Zone of Coagulation,Central area of burn Necrotic from time of exposure,Zone of Stasis,Moderate degree of insult Decreased tissue perfusion Vascular damage/ leakage May progress to necrosis 24-48 hours,Zone of Hyperemia,Vasodilation Inflammation Viable tissue,Bodys Res
13、ponse to Burns,Emergent Phase (Stage 1) 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 t
14、o cells Shift of fluid from intravascular to extravascular space MASSIVE EDEMA “Leaky Capillaries,Systemic Changes,Massive release of inflammatory mediators Produce vasoconstriction/ dilation Increased capillary permeability Edema,Fluid Shifts,Initial decrease blood flow to burned area Followed by i
15、ncreased arterial vasodilation Release of vasoactive substance resulting in increased capillary permeability and edema,Cardiovascular,Loss of plasma volume Increased peripheral vascular resistance Decreased cardiac outputdecreased blood volumedecreased venous returnincreased blood viscositydecreased
16、 contractility,Renal,Decrease circulating plasma Increase hematocrit Decreased COdecreased renal blood flowoliguriaacute renal failure,Gastrointestinal,Decreased gastrointestinal blood flow Increased mucosal hemorrhage 20% ileus,Immune System,Depressed immune function 20% directly proportional to bu
17、rn size,sepsis,Bodys Response to Burns,Hypermetabolic Phase (Stage 3) Last for days to weeks Large increase in the bodys need for nutrients as it repairs itself Resolution Phase (Stage 4) Scar formation General rehabilitation and progression to normal function,Hypermetabolism,Following severe burn a
18、nd resuscitationtachycardiaincreased COincreased O2 demandmassive proteolysis & lipolysissevere nitrogen loss,Systemic Complications,Hypothermia Disruption of skin and its ability to thermoregulate Hypovolemia Shift in proteins, fluids, and electrolytes to the burned tissue General electrolyte imbal
19、ance Eschar Hard, leathery product of a deep full thickness burn Dead and denatured skin,Systemic Complications,Infection Greatest risk of burn is infection Organ Failure Release of myoglobin Special Factors Age & Health Physical Abuse Elderly, Infirm or Young,Critical Burn Areas,Face Hands Feet Gro
20、in Joints Circumfrential,Inhalation Injuries,Leading cause of deathClosed space incidentPresence of heavy smokeHistory of unconsciousness,Burns, thermal. Partial- and full-thickness burns from structure fire. Note facial involvement.,Inhalation Injury,Toxic Inhalation Synthetic resin combustion Cyan
21、ide & Hydrogen Sulfide Systemic poisoning More frequent than thermal inhalation burn 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 & Hyperc
22、arbia,Other Evidence,Facial burns Profuse secretions Carbonaceous sputum Lacrimation Singed nasal hair,Hoarseness Wheezing Stridor Edema Hypoxemia Tachycardia,Inhalation Injury,Airway Thermal Burn Supraglottic structures absorb heat and prevent lower airway burns Moist mucosa lining the upper airway
23、 Injury is common from superheated steam 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
24、obstruction and arrest due to swelling,Types of Injuries,Carbon monoxide poisoning Injury above glottis Injury below glottis,CO Poisoning,Affinity for Hgb 200-250X than O2 Cherry red only present at levels 40% +N,+V, HA, decreased LOC, weakness, tachypnea, tachycardiaFalse pulse oximetry reading,100
25、% O2 time for elimination40 min 21% O2 time elimination250 minutes,Carboxyhemoglobin,Normal- 0 Smokers, truck drivers in heavy traffic- 15 15-40%- neurological dysfunctionweakness, dizziness, +N, +V, HA 40-60%- obtunded severe decreased LOC Consider hyperbaric therapy- 25-40%,Injury Above Glottis,Th
26、ermal, chemical Require early intubation Severely hypovolemic,Injury Below Glottis,Usually chemical Repiratory distress Require early intubation ARDS MSOF,Estimating % BSA Burned,Rule of palms Rule of nines,Body Surface Area,Rule of Nines Best used for large surface areas Expedient tool to measure e
27、xtent of burn Rule of Palms Best used for burns 10% BSA,Rules of Nines,Rule of Palms,A burn equivalent to the size of the patients hand is equal to 1% body surface area (BSA),Treatment,Stop the burn ABCs Estimate % BSA burned Cool burn Prevent hypothermia & infection Pain control,Airway,O2 on ALL pa
28、tientsAcute pulmonary insufficiencyPulmonary edema 2-3 daysBronchopneumonia 5-7 days Consider intubation Sx/ liklihood of impending airway obstruction,Circulation,Fluid replacement critical to survival Tissue destruction results in increased capillary permeability Profound fluid loss from the intrav
29、ascular space Large amounts fluid lost from loss of skin integrity due to evaporation,Parkland Formula,4ml x wt kg x %BSA burned = 24 hr infusion 1st half over first 8 hours Calculated from time of injury 2nd/ 3rd degree burns only,Fluid Resuscitation,Restore effective plasma volume Maintain vital o
30、rgan function Hypovolemia/ renal failure- complications Pulmonary edema Assess adequacy by UA output,Cool Burn,Within 30 minutesinhibits lactate production and acidosispromotes catecholamine function and ardiovascular homeostasisinhibits burn wound histamine releaseblocks histamine mediated increase
31、d vascualr permeability,Cont,minimizes edema formationsuppresses thromboxanemediator of vascular occlusionprogressive dermal ischemia,Hypothermia & Infection,Cover with dry sterile sheet Keep warm,Pain Control,Morphine sulfatedecreases amount of protein bindingrapidly eliminatedsmall, frequent doses
32、may use up to 50mg/hr Fentanyl Versed,Special Considerations,Circumfrential burnsmay require fasciotomy Pediatricsmore susceptible to circumfrential 6 mo no shivering mechanismnorepi converts brown fat,Burn Center,2nd/3rd degree burns 10% 50 2nd/3rd degree burns 20% TBSA 2nd/3rd degree burns to crit
33、ical areas 3rd degree 5% TBSA Significant electrical/ chemical burns Inhalation injury Circumfrential burns Preexisiting conditions medical or concomitant trauma,Scene Size-up Fire Department SCBA and protective clothing Initial Assessment ABCs MUST be intact Consider ET or RSI Rapid evacuation of p
34、atient if scene is unstable,Assessment of Thermal Burns,Focused and Rapid Trauma Assessment 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” bu
35、rns Age of patient affected,Assessment of Thermal Burns,Pain Changes in skin condition at affected site Adventitious sounds Blisters Sloughing of skin Hoarseness Dysphagia Dysphasia,Assessment of Thermal Burns General Signs & Symptoms,Burnt hair Edema Paresthesia Hemorrhage Other soft tissue injury
36、Musculoskeletal injury Dyspnea Chest pain,Assessment of Thermal Burns,Any partial or full thickness burn involving hands, feet, joints, face, or genitalia,30% BSA,Partial Thickness,Inhalation Injury,10% BSA,Full Thickness,Critical,2% BSA,Full Thickness,50% BSA,Superficial,2% BSA,Full Thickness,15% B
37、SA,Partial Thickness,50% BSA,Superficial,15% BSA,Partial Thickness,Moderate,Minor,Burn Severity,Ongoing Assessment Non-critical: Reassess Q 15 min Critical: Reassess Q 5 minBurn Center Care,Assessment of Thermal Burns,Local & Minor Burns Local cooling Partial thickness: 15% of BSA Full thickness: 2%
38、 BSA Remove clothing Cool or Cold water immersion Consider analgesics,Management of Thermal Burns,Moderate to Severe Burns Dry sterile dressings Partial thickness: 15% BSA Full thickness: 5% BSA Maintain warmth Prevent hypothermia Consider aggressive fluid therapy Moderate to severe burns Burns over
39、 IV sites Place IV in partial thickness burn site.,Management of Thermal Burns,Parkland Burn Formula4 mL x Pt wt in kg x % BSA = Amt of fluidPt should receive of this amount in first 8 hrs. Remainder in 16 hrs Consider 1 hour dose 0.5ml x Pt wt in kg x % BSA = Amt of fluid,Management of Thermal Burn
40、s,Moderate to Severe Burns Caution for fluid overload Frequent auscultation of breath sounds Consider analgesic for pain Morphine Nubain Prevent infection,Management of Thermal Burns,Inhalation Injury Provide high-flow O2 by NRB Consider intubation if swelling Consider hyperbaric oxygen therapy Cyan
41、ide Exposure Sodium Nitrite, Amyl Nitrite, Sodium Thiosulfate Forms methemoglobin binds to cyanide Non-toxic substance secreted in urine Inhale 1 ampule of Amyl Nitrite 300 mg Sodium Nitrite over 2-4 minutes 12.5 gm of Sodium Thiosulfate,Management of Thermal Burns,Scenario,Lightning Injuries,One of
42、 the top three causes of environmental death (flood, temp extremes) Not AC or DC but a unidirectional, massive, current impulse with several return strokes back to the cloud Tremendously large current impulsively flows for an incredibly short time,Difference Between Lightning and Electricity,Duratio
43、n of exposure to current Not enough time for skin burns Internal burns and renal failure usually inconsequential Cardiac arrest Respiratory arrest Vascular spasm Neurological damage,Immediate,Ventricular asystole Often spontaneously resume Prolonged respiratory arrest Results in secondary cardiac ar
44、rest Ischemia due to vascular spasms MI, spinal artery syndromes,Long Term,Survivors 10-20x fatalities Neuropsychological and neurocognitive changes Chronic pain syndromes Chest pain Sympathetic nerve system dysfunction Sleep disorders, HA, cardiac effects,Demographics,Sunday, Saturday, Wednesday No
45、on- 6pm, 6- 12 pm May be in or outdoors Males, 16 yo or 26- 35 yo,Blunt Injuries,Muscular contractions Instantaneous expansion and contraction of surrounding air,Cardiorespiratory Arrest,Only known direct cause of death “Cosmic defibrillation” Momentary asystole Spontaneous recovery Prolonged respir
46、atory arrest Hypoxia Secondary cardiac arrest,Neurologic,May present only mildly disorientated May still sustain disabling neurocognitive deficits similar to blunt head injury May not be immediately apparent,Pain,Pain Numbness Abnormal sensations Chronic pain syndromes may develop due to sympathetic
47、 NS injury,Sympathetic NS Injury,May cause vascular spasm Temporary paralysis Mottling Transient hypertension Late problems with + tilt tests Vertigo/ dizziness Pain syndromes,Brain injury may occur Deep burns rare Superficial burns more common Punctate, fern like, linear Secondary to metal in pocke
48、ts/ clothing Ear drum rupture common Direct current entry Concussive/ explosive force Basilar skull fx,Treatment,Resuscitation Spinal immobilization NSAIDS Prevent long term nuerological damage Treat chronic pain syndromes Ibuprofen, ketoprofen, naproxen,Prevention,Awareness of weather forecast Evac
49、uation May travel 10 miles from thunderstorm, clouds/ rain may not be present Shelter- school buses, metal top vehicles Avoid trees, small shelters, bleachers, fences, towers, any current transmitting structures, pools/ water, high areas Avoid use telephones, electronic equipment, any contact with conductive surfaces inside (plumbing, doing dishes), EMS/ fire dispatch radio,Arcing electrical burns, through shoe around rubber sole. High-voltage (7600 V) alternating current,Electrical,Age related injury peaksinfancy-4 years20-25 year old males- primarily work related,
