Burn Injuries GK

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Burn Injuries



Introduction

Thermal injuries are major causes ofmorbidity and mortality. Attention to

the basic principles of initial traumaresuscitation and timely applicationof simple emergency measures canhelp to minimize the morbidity and

mortality caused by these injuries.



Epidemiology

Tissue injury caused by thermal,electrical, or chemical agents

Can be fatal, disguring, orincapacitating

~ 1.2 million burn injuries peryear• !,""" hospitalized per year• !"" die per year #$%" from

houseres&

$rd largest cause of accidentaldeath



Risk Factors

'ire(Combustion• 'ireghter

•)ndustrial *or+er

• ccupant of burning structures

Chemical -posure• )ndustrial *or+er

-lectrical -posure• -lectrician

• -lectrical /o0er istribution *or+er



Skin

argest body organ. 3uch morethan a passi4e organ.•

/rotects underlying tissues from injury• Temperature regulation

• Acts as 0ater tight seal, +eeping body5uids in

• 6ensory organ



Skin

)njuries to s+in 0hich result in loss,ha4e problems 0ith7•

)nfection• )nability to maintain normal 0ater

balance

• )nability to maintain body temperature



Skin

T0o layers• -pidermis

•ermis

-pidermis• uter cells are

dead

• Act as protectionand form 0atertight seal



Skin

-pidermis• eeper layers di4ide to produce the

stratum corneum and also containpigment to protect against 89radiation

ermis•

Consists of tough, elastic connecti4etissue 0hich contains specializedstructures



Skin

ermis : 6pecialized 6tructures• ;er4e endings

•<lood 4essels

• 60eat glands

• il glands : +eep s+in 0aterproof,usually discharges around hair shafts

• =air follicles : produce hair from hairroot or papilla – Each follicle has a small muscle (arrectus pillorum) which can

pull the hair upright and cause goose flesh



Burn Injuries

/otential complications• 'luid and -lectrolyte loss

=ypo4olemia• =ypothermia, )nfection, Acidosis

• catecholamine release,4asoconstriction

•

>enal or hepatic failure• 'ormation of eschar

• Complications of circumferential burn



Burn Injuries

An important step in managementis to determine depth and etent of

damage to determine 0here andho0 the patient should be treated



Types of Burn Injuries

Thermal burn• 6+in injury

•

)nhalation injury Chemical burn

• 6+in injury

• )nhalation injury

• 3ucous membrane injury -lectrical burn

• ightning

>adiation burn



Depth Classification

6upercial

/artial thic+ness

'ull thic+ness



Burn Classifications

1st degree #6upercial burn&• )n4ol4es the epidermis

•Characterized by reddening

• Tenderness and /ain

• )ncreased 0armth

• -dema may occur, but no blistering

• <urn blanches under pressure• -ample : sunburn

• 8sually heal in ~ % days




First Degree Burn

(Superficial Burn)




2nd degree• amage etends through the

epidermis and in4ol4es the dermis.• ;ot enough to interfere 0ith

regeneration of the epithelium

• 3oist, shiny appearance

•

6almon pin+ to red color• /ainful

• oes not ha4e to blister to be 2nddegree

•8sually heal in ~%:21 days




2nd egree<urn#/artialThic+ness<urn&




$rd degree• <oth epidermis and dermis are

destroyed 0ith burning into 6? fat• Thic+, dry appearance

• /early gray or charred blac+ color

• /ainless : ner4e endings are destroyed

• /ain is due to intermiing of 2nddegree

• 3ay be minor bleeding

• Cannot heal and re@uire grafting




3rd Degree Burn

(Full Thickness burn)





Burn Injuries

ften it is not possible to predictthe eact depth of a burn in the

acute phase. 6ome 2nd degreeburns 0ill con4ert to $rd 0heninfection sets in. *hen in doubtcall it $rd degree.



Body Surface Area Estimation

>ule of

;ines• Adult

/alm

>ule



Body Surface Area Estimation

>ule of;ines•

/eds – For each yr

over 1 yoa,

subtract 1%

from head and

add equally tolegs

/alm >ule





Burn atient Se!erity

'actors to Consider• epth or Classication

•

<ody 6urface area burned• Age7 Adult 4s /ediatric

• /reeisting medical conditions

• Associated Trauma

– blast injury – fall injury

– airway compromise

– child abuse



Burn atient Se!erity

/atient age• ess than 2 or greater than

•

=a4e increased incidence ofcomplication

<urn conguration• Circumferential burns can cause total

occlusion of circulation to an area dueto edema

• >estrict 4entilation if encircle the chest

• <urns on joint area can cause disability

due to scar formation



Critical Burn Criteria

$" 1"B <6A

2" $"B <6A

• 2"B pediatric <urns 0ith respiratory injury

=ands, face, feet, or genitalia

<urns complicated by other trauma 8nderlying health problems

-lectrical and deep chemical burns



"oderate Burn Criteria

$" 2:1"B <6A

2" 1:$"B <6A

• 1":2"B pediatric -cluding hands, face, feet, or

genitalia

*ithout complicating factors



"inor Burn Criteria

$" 2B <6A

2" 1B <6A

• 1"B pediatric 1" 2"B <6A



Thermal Burn Injury

athophysiology

-mergent phase• >esponse to pain catecholamine

release 'luid shift phase

• massi4e shift of 5uid : intra4ascular etra4ascular

=ypermetabolic phase• demand for nutrients repair tissue

damage

>esolution phase• scar tissue and remodeling of tissue



Thermal Burn Injury

athophysiology

Dac+sonEs Thermal *ound Theory• Fone of Coagulation

– area nearest burn

– cell membranes rupture, clotted blood and thrombosed vessels

• Fone of 6tasis – area surrounding one of coagulation

– inflammation, decreased blood flow

• Fone of =yperemia – peripheral area of burn

– limited inflammation, increased blood flow



Thermal Burn Injury

athophysiology

-schar formation• 6+in denaturing

– hard and leathery

• 6+in constricts o4er 0ound – increased pressure underneath

– restricts blood flow

• >espiratory compromise – secondary to circumferential eschar around the thora!

• Circulatory compromise – secondary to circumferential eschar around e!tremity



# h a t i s m y fi s t p i o i ty $

ifesa4ing measures for patients0ith burn injuries include

establishing air0ay control,stopping the burning process,and establishing intra4enous

access.



Clinical indications of inhalation injury include%

'ace and(or nec+ burns

6ingeing of the eyebro0s and nasal4ibrissae

Carbon deposits and acute in5ammatorychanges in the oropharyn

Carbonaceous sputum

=oarseness =istory of impaired mentation and(or

connement in a burning en4ironment

-plosion 0ith burns to head and torso

Carboyhemoglobin le4el greater than1"B in atient 0ho 0as in4ol4ed in a re



AIR#A&

Transfer to a burn center is indicatedif there is inhalation in jury. )f the

transport time is prolonged,intubation should be performed priorto transport to protect the air0ay.The symptom of stridor is an

indication for immediateendotracheal intubation.Circumferential burns of the nec+ canlead to s0elling of the tissues around

the air0ay. Therefore, early in



REAT'I()

/atients 0ith C le4els of less than2"B usually ha4e no physical

symptoms. =igher C le4els canresult in7 #1& headache and nausea#2"B:$"B&, #2& confusion #$"B:!"B&,#$& coma #!"B:G"B&, and #!& death

#G"B&.<aseline carboyhemoglobin le4elsshould be obtained, and 1""Boygen should be administered.



ST* T'E +R(I() R*CESS

All clothing should be remo4ed tostop the burning processH ho0e4er,

do not peel oI adherent clothing. rychemical po0ders should be brushedfrom the 0ound, 0ith the indi4idualcaring for the patient a4oiding direct

contact 0ith the chemical, and thein4ol4ed body:surface areas shouldbe rinsed 0ith copious amounts oftap 0ater. The patient then should be

co4ered 0ith 0arm, clean, dry linens



Assessment , "anagement -

Thermal Injury

>emo4e to safe area, if possible

6top the burning process•

-tinguish re : cool smoldering areas• >emo4e clothing and je0elry

• Cut around areas 0here clothing isstuc+ to s+in

• Cool adherent substances #Tar, /lastic&



I(TRA.E(*+S ACCESS

Any patient 0ith burns o4er morethan 2"B of the body surface

re@uires 5uid resuscitation.arge:caliber #at least J1G:gauge&intra4enous lines should beintroduced immediately in a

peripheral 4ein.The upper etremities are preferableto the lo0er etremities for 4enous

access because of the high incidenceof hlebitis and se tic hlebitis 0hen

A "




Thermal Injury

/ertinent =istory• =o0 long agoK

•

*hat care has been gi4enK• *hat burned 0ithK

• <urned in closed spaceK – "roducts of combustion present#

–

$ow long e!posed# – oss of consciousness#

• /ast medical historyK



'IST*R&

Associated injuries

Time of the burn injury

<urns sustained 0ithin an enclosedspace suggest the potential forinhalation injury.

/reeisting illnesses #eg, diabetes,hypertension, cardiac, pulmonary,and(or renal disease& and drugtherapy.

Tetanus immunization status .




Thermal Injury

Circulatory 6tatus• <urns do not cause rapid onset of

hypo4olemic shoc+ • )f shoc+ is present, loo+ for other

injuries

• Circumferential burns may cause

decreased perfusion to etremity

A t " t




Thermal Injury

ther• Assess <urn 6urface Area L Associated

)njuries• Analgesia

• A4oid topical agents ecept as directedby local burn centers – e&g& silvadene

• 'luid Therapy

A t " t




Thermal Injury

Consider 'luid Therapy for• 1"B <6A $"

•

1B <6A 2"

• $":"B <6A 1" 0ith accompanying 2"

> using /ar+land <urn 'ormula• ! #2:!& cc(+g(B burn

• 1(2 in rst M hours• 1(2 o4er 2nd 1G hours




Thermal Injury

'luid therapy• bjecti4e

–

$' 11*minute – +ormal sensorium (awae, alert, oriented)

– -rine output . /.0 cc*hour (adult) &0.1 cc*g*hr (pedi)

– 'esuscitation formula2s provide estimates, adjust to individual

patient responses

• 6tart through burn if necessary, upperetremities preferred

• 3onitor for /ulmonary -dema

Assessment , "anagement




Thermal Injury

Analgesia• 3orphine 6ulfate

–

3./ mg repeated q 1 minutes titrated to adequate ventilationsand blood pressure

– &1 mg*g for pediatric

– 4ay require large but tolerable total doses

Assessment , "anagement




Thermal Injury

Treat <urn *ound• o0 priority : After A<CEs and initiation

of )9Es• o not rupture blisters

• Co4er 0ith sterile dressings – 4oist5 6ontroversial, limit to small areas (1%) or limit time

of application

– 7ry5 -se for larger areas due to concern for hypothermia

– 6over with burn sheet

• ;o NOooP on burn unless directed byburn center



Chemical Burns

8sually associated 0ith industrialeposure

'irst Consideration7 6hould you behereK• oes the patient need decontamination

before treatmentK

<urning 0ill continue as long as thechemical is on the s+in



Chemical Burns

Acids• )mmediate coagulation:type necrosis

creating an eschar though self:limitinginjury – coagulation of protein results in necrosis in which affected

cells or tissue are converted into a dry, dull, homogeneous

eosinophilic mass without nuclei



Chemical Burns

<ases #Al+ali&• i@uefacti4e necrosis 0ith continued

penetration into deeper tissueresulting in etensi4e injury – characteried by dull, opaque, partly or completely fluid

remains of tissue

ry Chemicals• -othermic reaction 0ith 0ater



Chemical Burn "anagement

eniti4e treatment is to get thechemical oIQ

<egin 0ashing immediately :remo4al the patientEs clothing asyou 0ash• *atch for the soc+s and shoes, they

trap chemicals




i@uid Chemicals• 0ash oI 0ith copious amounts of 5uid

ry Chemicals• brush a0ay as much of the chemicals

as possible

• then 0ash oI 0ith large @uantities of

0ater 'lush for 2":$" minutes to remo4e

all chemicals




o not attempt neutralization• can cause additional chemical or

thermal burns from the heat ofneutralization

Assess and eli4er secondary careas 0ith other thermal and

inhalation burns



Chemical Burn to Eye

"anagement

'lood the eye 0ith copiousamounts of 0ater only•

;e4er place chemical antidote in eyes 'lush using >(;6(=2 from medial

to lateral for at least 1 minutes• ;asal Cannula

• )9 Ad 6et

>emo4e contact lenses• 3ay trap irritants



Specific Chemical

Considerations

ry lime• <rush oI

•

ry lime is 0ater acti4ated• Then 5ush 0ith copious amounts of

0ater

/henol

• ;ot 0ater soluble• )f a4ailable, use alcohol before 5ushing

ecept in eyes

• )f una4ailable, use copious amounts of

0ater



Specific Chemical

Considerations

6odium(/otassium metals• >eacts 4iolently on contact 0ith =2"

•

>e@uires large amounts of 0ater 6ulfuric Acid

• Oenerates heat on eposure to =2#eothermic&

•*ash 0ith soap to neutralize or usecopious amounts =2

Tar <urns• 8se cold pac+s

• o not pull oI, can be dissol4ed later



Specific Chemical

Considerations

Chemical 3ace• C; or C6

– First chemical agents used by police*military

• 3ucous membrane and respiratorytract irritant

• 6+in sensitizer

• 3anagement – 8reat respiratory distress

– 6ontinued irrigation and shower decontamination

– "rotect yourself first

– 7econtaminate everything afterward

S C



Specific Chemical

Considerations

Chemical 3ace• C

– 6ommonly referred to as 9pepper spray:

• ;ot as toic as C; or C6• 3ucous membrane irritant and s+in

sensitizer

• 3ay cause respiratory irritation

• 3anagement – 8reat respiratory distress

– 6ontinued irrigation and shower decontamination

– "rotect yourself first

–7econtaminate everything afterward



Electrical Burns

8sually follo0s accidental contact0ith eposed object conducting

electricity• -lectrically po0ered de4ices

• -lectrical 0iring

• /o0er transmission lines

Can also result from ightning amage depends on intensity of

current



Electrical Burns

Current +ills, 4oltage simplydetermines 0hether current canenter the body• hmEs la07 )R9(>

-lectrical follo0s shortest path toground

o0 9oltage• usually cannot enter body unless7

– ;in is broen or moist

– ow 'esistance (follows blood vessels*nerves)

=igh 9oltage



Electrical Burns

6e4erity depends upon7• 0hat tissue current passes through

•

0idth or etent of the current path0ay• AC or C

• duration of current contact



Electrical Burns

3ost damage done is due to heatproduced as current 5o0s through

tissues 6+in burns 0here current enters

and lea4es can be almost tri4ialloo+ing

• -4erything bet0een can be coo+ed =igher 4oltage may result in more

ob4ious eternal burns



Electrical Burns

Alternating Current #AC&• Tetanic muscle contraction may occur

resulting in7 – 4uscle injury

– 8endon 'upture

– <oint 7islocation

– Fractures

• 6pasms may +eep patient from freeingoneself from current



Electrical Burns

Contact 0ith Alternating Currentcan also result in7•

Cardiac arrhythmias• Apnea

• 6eizures



Electrical Burns

)n addition to contact burns,patients can also de4elop 5ash

burns 0hen the current arcs nearthem• 'lame burns may occur 0hen clothing

ignites after eposure to electrical

current



Electrical Burns

ightning• =)O= 9TAO-QQQ

•

)njury may result from – 7irect ;trie

– ;ide Flash

• 6e4ere injuries often result

• /ro4ides additional ris+ to -36pro4ider – =eather capable of producing lightning is still in the area



Electrical Burns

/athophysiology of )njuries• -ternal <urn

•

)nternal <urn• 3usculos+eletal injury

• Cardio4ascular injury

• >espiratory injury

•

;eurologic injury• >habdomyolysis and >enal injury



Electrical Burn "anagement

3a+e sure current is oI • ightning hazards

• o not go near patient until current is

oI

A<CEs• 9entilate and perform C/> as needed

•

ygen• -CO monitoring

– 8reat dysrhythmias




>habdomyolysis Considerations• 'luidK

•

opamineK Assess for additional injuries

Consider transport to traumacenter




Any patient 0ith an electrical burn regardless of ho0 tri4ial it loo+sneeds to go to the hospital. There isno 0ay to tell ho0 bad the burn is

on the inside by the 0ay it loo+s onthe outside.



Radiation E/posure

*a4es or particles of energy that areemitted from radioacti4e sources• Alpha radiation

– large, travel a short distance, minimal penetrating ability

– can harm internal organs if inhaled, ingested or absorbed

• <eta radiation – small, more energy, more penetrating ability

–usually enter thru damaged sin, ingestion or inhalation

• Oamma radiation L S:rays – most dangerous penetrating radiation

– may produce localied sin burns and e!tensive internal damage



Radiation E/posure

>adiation eposure may result in7• eternal injury

•

contamination• incorporation injury

• combined injuries



Radiation E/posure

-Iect of )njury dependent upon7• duration of eposure

•

distance from the source• shielding

At ris+ for delayed complications



Radiation E/posure "anagement

6A'-TQQQ• T0o 3ost 8seful Tools for >adiation

)ncident 3anagement

• /rotecti4e -@uipment

;eed for decontamination

i+elihood of sur4i4al

A<Cs and 6upporti4e Care



ediatric Burns

Thin s+in• increases se4erity of burning relati4e to

adults

arge surface(4olume ratio• rapid 5uid loss

• increased heat loss hypothermia

elicate balance bet0eendehydration and o4erhydration

)mmature immunological response sepsis



)eriatric Burns

ecreased myocardial reser4e• 5uid resuscitation diUculty

/eripheral 4ascular disease,diabetes• slo0 healing

C/• increases complications of air0ay

injury

/oor immunological response :6epsis



CRITERIA F*R TRA(SFER

/artial:thic+ness and full:thic+ness burns ofgreater than 1"B of the <6A in patients less than1" years or o4er " years of age

/artial:thic+ness and full:thic+ness burns ongreater than 2"B of the <6A in other age groups

/artial:thic+ness and full:thic+ness burnsin4ol4ing the face, eyes, ears, hands, feet,genitalia, and perineum, as 0ell as those thatin4ol4e s+in o4erlying major joints

'ull:thic+ness burns on greater than B of the<6A in any age group

6ignicant electrical burns, including lightninginjury #signicant 4olumes of tissue beneath thesurface can be injured and result in acute renalfailure and other com lications&



CRITERIA F*R TRA(SFER

6ignicant chemical burns

)nhalation injury

<urn injury in patients 0ith preeisting illness

that could complicate treatment, prolongreco4ery, or aI ect mortality

Any patient 0ith a burn injury 0ho has concomitant trauma poses an increased ris+ of morbidityor mortality, and may be treated initially in a

trauma center until stable before beingtransferred to a burn center

Children 0ith burn injuries 0ho are seen inhospitals 0ithout @ualied personnel ore@uipment to manage their care should be

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Burn Injuries GK

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