Burns
Burns
John van der Steeg MD
Objectives
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Incidence and patterns of burn injury
Pathophysiology of local and systemic responses
to burn injury
Classify burn
Physical exam of the burned patient
Prehospital management of burned patient
Signs and symptoms of inhalational injury which
may influence management
Criteria for transport to a Burn Center
Incidence and Pattern of Burn
Types
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Tissue injury caused by thermal, electrical,
radiation or chemical agents
Burns are another form of trauma
Associated with high mortality, lengthy
rehabilitation.
Greater than 2 million people/yr. seek care for
burns.
Morbidity and Mortality follow significant
patterns regarding gender, age, and
socioeconomic status
Skin
Largest body organ.
 Not a passive organ.
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– Protects underlying tissues from injury
– Temperature regulation
– Acts as water tight seal
– Sensory organ
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Very young and old have thin skin thus
short contact time = greater damage
when compared to mid aged persons
Skin concerns after burns
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Infection
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Problems with thermal regulation
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Inability to maintain normal water balance
Skin layers
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Two layers
– Epidermis
– Dermis
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Epidermis
– Outer cells are dead
– Protective barrier and
water tight seal
– Deeper layers contain
pigment to protect against
UV radiation and produce
stratum corneum
Skin Layers
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Dermis
– Consists of tough,
elastic tissue which
contains specialized
structures such as hair
follicles, sweat glands,
blood vessels, oil
glands, and nerve
endings
Classification of Burns
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First degree /
superficial burnpainful, red, and dry
and blanch with
pressure.
Classification of Burns
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2nd degree / partial
thickness burncharacterized by
blisters, injury
extends through the
dermis to the
epidermis, basal
layers of skin are not
destroyed
Classification of Burns
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3rd degree / full thickness
burns- Entire thickness of
dermis and epidermis is
destroyed. Wound
characterized by
coagulatin necrosis and
appears pearly white,
charred or leathery.
Sensation and cap refill
are absent.
Factors which affect Burn injury
Water content
 Skin thickness
 Skin pigment
 Presence of absence of insulating
substances
 Peripheral circulation
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Tissue damage depends on
temperature and time
Surface temperature of 44 C (111 F) begins to
produce burns. But is dependent on exposure
time.
 Temperature >44C and < 51C (124F) the rate of
epidermal necrosis doubles with each degree of
temperature increase.
 At > 70 C (185F) or greater, exposure time
required to cause transepidermal necrosis is less
than 1 second.
 Normal process of water evaporation is
accelerated 5 to 15 time to that of normal skin.
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Pathophysiology of Burns
(Local response)
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Based on Jackson’s
thermal wound theory
Zone of hyperemia
– Increased blood flow due
to normal inflammatory
response
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Zone of stasis
– Potentially viable tissue
– Cells are ischemic due to
clotting and
vasoconstriction
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Zone of coagulation
– Coagulation necrosis has
occurred
– Tissue is non viable
Pathophysiology of Burns
(Systemic response)
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Hypovolemic shock/”Burn shock”
– Response proportional to extent of body surface
injury
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Pulmonary response
Gastrointestinal response
Musculoskeletal response
Neuroendocrine response
Metabolic response
Immune response
Emotional response
Burn injuries
(Primary Survey)
Recall that burn patients are first and
foremost trauma patients
 Airway
 Breathing
 Circulation
 Disability
 Exposure
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Airway
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Airway control
– Chin lift
– Jaw thrust
– Insert oral pharyngeal
airway
– Assess need for ET
intubation
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Maintain in-line
cervical
immobilization in
patients at risk
Breathing
Listen: verify breath sounds
 Assess rate and depth of respirations
 Administer high flow O2
 Monitor chest wall excursion in presence
of full thickness torso burns
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Inhalational injury
Present in 10 – 20 % of burn patients
 Identified in 60 – 70 % of patients who
die in burn centers
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Airway assessment and
management
Humidified 100% O2 by mask
 Endotracheal intubation indicated if
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– Airway obstruction imminent as signaled by
progressive hoarseness and/or stridor
– LOC is such that airway protective reflexes are
impared
Warning signs/clues
Facial burns, singed nasal hairs
 Carbonaceous sputum
 Tachypnea, intercostal retractions
 Hoarsness
 Agitation (hypoxia)
 Rales, rhonchi, diminished breath sounds
 Inability to swallow
 Naso or oro-pharynx erythema
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Circulation
Monitor BP, pulse rate, skin color
 Establish IV access
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– If possible, place iv in non-burned skin, but
may place it in burned skin if needed.
– How would you secure IV in burned tissue?
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Assess circulatory status of
circumferentially burned extremities
Disability, Neurologic Deficits
Typically alert and oriented. If not, why
not?
 Remember AVPU?
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– A-Alert
– V-Responds to verbal stimuli
– P-Responds to painful stimuli
– U-Unresponsive
Disability, Neurologic Deficits
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Please remember before you intubate, if
possible, to get any pertinent history
– AMPLE history
– A – Allergies
– M – Medications
– P – Previous medical/surgical history
– L – Last meal (time)
– E – Events/environment surrounding the
injury; ie. Exactly what happened
Exposure/Environmental control
First must remove patient to a safe area
 Stop the burning process
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– Exstinguish fire – cool smoldering areas
– Remove ALL clothing and ALL jewelry
– Cut around areas where clothing is stuck to
the skin
– Cool adherent substances (Tar, Plastic)
Exposure/Environmental control
Once patient in safe area
 Maintain patient’s temperature
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– Warm room or rig
– Keep patient covered; dry sheets, blankets
– Warm IV fluids
Circumstances of Injury
Circumstances of Injury: Flame
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How did it occur?
– Inside or outside?
– Clothing ignition?
– Time to extinguish flame?
– Extinguished how?
– Gasoline or other fuel involved?
– Explosion? Patient thrown?
– Are purported circumstances of injury
consistent with burn characteristics?
Circumstances of Injury: Flame
Structure fire?
 Smoke filled space?
 Others injured or killed in event?
 Was there LOC at the scene?
 How did the patient escape
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– Did the patient jump? How far was the drop?
– Through glass?
Circumstances of Injury: Flame
Automobile crash?
 How badly was the car damaged?
 Other injuries?
 Did they hit anybody? Check around,
under the vehicle.
 Car fire?
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Circumstances of Injury: Scald
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What is the history of the injury?
– What was the liquid?
– What was the volume of liquid involved?
– What was the temperature of the liquid?
 If tap water, what was the heater temperature setting?
 If heated by other source, was the liquid boiling
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Was the patient wearing clothing?
How quickly was it removed?
Was the burned area cooled?
Was other first aid administered?
Circumstances of Injury: Scald
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Is abuse or neglect
suspected?
– How quickly was care
sought?
– Where did the burn
occur?
– Who was with the
patient when the
injury occurred?
– Does the story fit the
injury?
Circumstances of Injury:Chemical
Circumstances of Injury:Chemical
What was the agent?
 Is it still around? Vapor?, Liquid?, Solid?
 How did the exposure occur?
 What was the duration of contact?
 What decontamination occurred?
 Was there an explosion? Was the patient
thrown?
 What is the toxicity of the agent?
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Circumstances of Injury:Electrical
What kind of current was involved?
 What was the duration of contact?
 Was the patient thrown or did the patient
fall?
 What was the estimated voltage?
 Was there LOC?
 Was CPR administered?
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Circumstances of Injury:Electrical
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The great pretender
– Small surface injuries may be associated with
severe internal injuries
– Causes about 1000 deaths/yr.
First contact
After patient in safe area…
 Complete head to toe exam
 Pre-existing medical conditions? Tetnus
status? Other injuries?
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Determine Burn Severity
You must assess % of body surface area
(BSA) involved
 Depth of injury (1st, 2nd, or 3rd degree)
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– Realize that this is difficult to do as burns may
“mature” over time AND getting an exact
percentage is usually not possible
Age of patient
 Associated / pre-existing disease or illness
 Burns to hands, face, genitalia.
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Extent of Burn
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Initial estimate of 2nd and
3rd degree burns: “rule of
nines”
– Adult areas = 9% BSA or
multiples
– Not accurate for
infants/children due to
larger BSA of head and
smaller BSA of legs.
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To estimate scattered
burns, palm of hands and
fingers of patient = 1%
BSA
Burn Depth
Very young and very old patients have
thinner skin
 Therefore, contact time at similar
temperatures will be worse for them.
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Pre-hospital management principles
Stop the burning process
 Universal precautions
 Initiate fluid resusucitation per the consensus
protocol:
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2 - 4 ml % BSA burn
½ in 1st 8 hrs
½ over next 16 hrs
*this is for adults only, pediatric patients require
consensus formula + D5LR maintenence fluids
Pre-hospital management principles
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Vital signs
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Assess extremity perfusion
– * remove all rings, watches, other jewelry
– *Elevation of burned areas if possible
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Ventilation status
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Pain relief/management
Initial Burn Wound Care
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Thermal burns
– Cover with clean, DRY cloth
– NO ice or cold water soaks
Initial Burn Wound Care
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Electrical Injury
– Be aware of both cutaneous an internal injury
 Entrance and exit points versus contact points
 Arcing wounds vs electrical flash wounds
– Consider electrical current cardiac effects
Initial Burn Wound Care
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Chemical burns
– Scene control
– Brush powders from skin and clothes
 Watch shoes and socks
– Remove contaminated clothing
– Flush with COPIUS amounts of water
– Eye irrigation if involved
– Exposure protection for yourselves and
anyone involved with patient care
Burn center referral criteria
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The ABA identifies the following as injuries
requiring a Burn Center referral:
– 2nd degree burns > 10% TBSA
– Burns to face, hands, feet, genitalia,
perineum, major Joints
– 3rd degree burns
– Electric injury (lightning included)
– Chemical burns
Burn center referral criteria
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Inhalational injuries
Burns accompanied by pre – existing medical
conditions
Burns accompanied by trauma, where burn
injury poses greatest risk of morbidity or
mortality
Burns to children in hospitals without pediatric
services
Patients with special social, emotional or
rehabilitative needs
Summary
Be able to assess injuries
 Be able to develop priority – based plan of
care
 Base care plan on type, extent, degree of
burn
 Consult with a burn center physician
 Decide upon local treatment and transport
with burn center physician
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Feel that burn…in your colon