PCP - GORD PATTERSON, ALS-A//V , ACP
Paramedic Burn Care
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Primary Care Paramedics:
 a critical link allowing serious Burns to
achieve maximally favourable outcomes
Burns must grab your attention
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You will be faced with this sometime in
your career
Visual appearance of injury can create
anxiety and scene management challenges
Goal Today is to prepare you to
manage burns
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To reinforce an understanding of the
anatomy and the pathophysiology of
burn dynamics.
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To enable the student to assess burn
characteristics to thereby provide
appropriate care to the burn victim.
Focus on thermal burns
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Burns described
Skin anatomy and function
Respiratory considerations
Fluid shifting
Burn Depth and Zones
Burn Severity
Size estimations
PCP management considerations
Dressing considerations & characteristics
Format – 2.5 hours
Introduction
 P/P Presentation
 Break out group Burn Classification
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 Group discussion
P/P Presentation
 Break out group Burn size estimation
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 Group discussion
P/P Presentation
 Summary
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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
Prevention Canada)
(Fire
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
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Burns described
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A burn is an injury to tissues caused by
heat, flame, chemicals, radiation,
friction. Burns are classified as
 Thermal
 Chemical
 Electrical
 Radiation
Burns characteristics defined by :
Mechanism of injury
 Depth of tissue damage
 Severity of injury to the patient
 Total body surface involved
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Injury mechanisms are further
grouped
Scalds
 Contact Burns
 Fire
 Chemical
 Electrical
 Radiation
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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
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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
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Skin Layers
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Epidermis – thinnest layer
 Tough protective barrier
 Protects internal organs
 Sensory aid
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Dermis
 Contains blood vessels, nerve endings
 Prevents water loss (evaporation)
 Prevents heat loss
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Hypodermis
 Subcutaneous tissue primarily fat, connective
tissue, and vascular structure
Skin – Rich in vascular structures
Burns damage vascular structure creating
capillary permeability & fluid shifting
Imagine this over 30% TBSA
Picture source emedicine.com
Fluid shifting occurs in two
stages
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Hypovolemic stage ( onset to ~ 36-48
hours)
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Diuretic stage ( ~ 48 - 72 hours after
injury)
Hypovolemic Stage
 Rapid fluid shifts - from the vascular compartments
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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
Diuretic Stage
 Capillary membrane integrity returns
 Edema fluid shifts back into vessels - blood
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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
Respiratory System
The airway epithelium are susceptible to injury from
inhaled hot gases and can be life threatening
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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
Continually monitor pulmonary
status
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Airway burns account for the majority of
immediate and delayed deaths from
burns (death up to 24 hours from injury)
Signs of a Respiratory Burn
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Red Flags
 History of a Closed area heat insult
 Productive cough
 Dyspnea
 Facial burns
 Singed nasal hair
 Sooty sputum
 Horse voice
Primary care of any burns begins
with:
Classification of burn depth
 Estimation of burn size
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Classification of burn depth is
determined by structures injured
Increasing severity
Epidermis
Dermis
Hypodermis
& deeper
Muscle,
tendons and
bone
Traditional Classification
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1st degree
 Epiderminal layer, red, painful
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2nd degree
 Epiderminal layer and some dermis, blisters,
painful
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3rd degree
 Full thickness epidermis, all dermis including
hypodermis
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4th degree
 Full thickness including hypodermis and deep
facia
New Classification
Superficial
 Superficial Partial Thickness
 Deep Partial Thickness
 Full Thickness
 Fourth Degree
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Superficial Burns
Epidermis
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Hypodermis &
deeper
Muscle, tendons and
bone
Involve only the epidermal layer of skin.
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Dermis
Red
Dry
Painful
Blanches
Heals spontaneously
Superficial
Superficial Partial Thickness
Epidermis
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Dermis
Hypodermis &
deeper
Muscle, tendons and
bone
Involve entire epidermis and superficial
portions of the dermis
 Painful , red and weeping usually from
blisters
 Blanches with pressure
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Generally heals spontaneously
Superficial Partial Thickness
Deep Partial Thickness
Epidermis
Dermis
Hypodermis &
deeper
Muscle, tendons and
bone
Involve entire epidermis
 Extends into deeper dermis damaging
glandular tissue and hair follicles
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 Blisters
 Wet or waxy dry
 Variable colour from patchy white to red
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May heal spontaneously
Deep Partial Thickness
Full Thickness Burns
Epidermis
Dermis
Hypodermis &
deeper
Muscle, tendons and
bone
Includes destruction of epidermis, the
entire dermis
 Damage to the hypodermis
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 Waxy white to leathery grey to charred and
black
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Less painful
May require skin grafting
Full Thickness Burn
Fourth Degree Burns
Epidermis
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Dermis
Hypodermis &
deeper
Muscle, tendons and
bone
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
Fourth degree burn
Break Out Group Pictures
Four Groups
 15 minutes
 Choose speaker to discuss burn
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Object:
 Assess Burn Depth
 Burn classification
 Distinguishing features
 Skin structures involved
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
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A single burn can be made up of
combination of classifications
Cell damages occurs in varying
degrees creating Burn Zones
Hyperemia
Zone
Stasis
Zone
Coagulation
Zone
• Minimal cell damage and
vascular engorgement
• Viable Injury
• Necrosis
Identify tissue viability
Critical burn body areas are:
Respiratory tract
 Face, eyes
 Hands & feet joint areas
 Perineum
 Circumferential burns
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Circumferential burns constrict
circulation
How does this occur
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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
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Fixes: Escharotomy or Fasiotomy
Is this patient sick?
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
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Accurate burn size estimation is
essential to determine severity
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Rule of Nines
Adult:
Head 9%
Arms 9%(each)
Torso (front/back)18%
Legs 18%
Perineum 1%
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Child:
Head18%
Arms 9% (each)
Torso (front/back) 18%
Legs14% (each)
Perineum1%
Palmer Method
 The area of the patient’s hand size including
the fingers is approximately 1% TBSA
Rule of Nines
Severity is further described as:
Major
Moderate
Minor
Minor Burn
Minor
 <10 percent TBSA burn in adult
 <5 percent TBSA burn in young or old
 <2 percent full thickness burn
Moderate Burn
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Moderate
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)
Major Burn
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Major
>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
 Significant associated injuries (e.g., fracture,
other major trauma)
Break Out Group Pictures
Four Groups
 15 minutes
 Choose speaker to discuss burn
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Object:
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Assess Burn Size
 TBSA
 Severity
 Structures involved
Burn Mortality
Management is focused to prevent
mortality and morbidly
Death from burns
 Initial 24 hours:
 respiratory burn
 hypovolemic shock
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After 24 hours:
 infection
 kidney failure
Primary Burn Management
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Scene Safe
ABC’s
Expose and examine
 Remove constricting jewellery/watches
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Initiate cooling (Thermal)
Flush chemicals off (Chemical)
High flow oxygen
Calculate TBSA
Evaluate injury depth
Evaluate injury severity
Burn Priorities
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Timely transport!
Prepare for urgent A/W interventions
 BV Mask passive assistance
 ALS backup
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Infection control (Damaged tissue & vascular bed
ideal conditions for bacteria growth)
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Cool then dress wounds dry sterile
Pain control as appropriate
Prevent hypotension/hypothermia
Appropriate hospital destination
Hospital communication
Thermal burns
PCP management considerations:
 Ensure scene safety
 Remove the patient from the source of the burn
 ABC’s
 High flow oxygen
 Assess for associated injuries
 Remove clothing and jewelry from burn sites
 Cool soaks with sterile water
 < 20% up to 30 minutes
 > 20% up to 10 minutes – Major burns no more than 10 minutes
Cover with dry sterile dressings or a clean sheet
Watch for and prevent hypothermia
 Pain management – Entonox (no inhalation injury)
 Venous access (large bore) – 500 ml NS bolus’ PRN up to
2 Litres to BP above 90 mmHg
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Chemical Burn
PCP management considerations:
 Paramedic safety - PPE
 Brush off dry chemical
 Flush with copious irrigation for 20
minutes
 Prevent hypothermia
Pain management – Entonox
 Venous access
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Electrical burns
PCP management considerations:
 Ensure scene is electrically safe
 Then remove the patient from the electrical
source
 ABC’s· High flow oxygen· Assess and treat
for associated injuries
 Moist sterile dressing to burn
 Pain management – Entonox
 Venous access (large bore) – 500 ml NS
bolus’ PRN up to 2 Litres to BP above 90
mmHg
Cool Soak Dressing management
Skin destruction removes the body's
primary insulation
 Heat loss can be rapid, especially in
children
 Cool with tepid isotonic solutions
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Cool Major burns no more
than 10 minutes
Risk of Hypothermia
Ideal dressing characteristics
Sterile
 Large enough to cover injury
 Absorbent fluid controlling
 Lint free
 Thermal insulation
 Non adhering
 Non constricting
 Allow expansion of underlying tissues
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Important emphasis
Create a sterile field for dressings
 Dressing must be loosely applied to protect
the injury from infection and control
drainage
 Non constricting
 An inappropriately applied dressing can
increase extent of injury by:
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 Compressing injury
○ Restricting blood flow
○ Compartment syndrome
○ Tissue hypoxia
○ Anaerobic metabolism and acidosis
Summary
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Do:
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Assess the A/W repeatedly, repeatedly
Stop the burning process
Oxygenate
Keep the patient warm
Apply loose dry sterile dressings
Give IV fluids
Consider ALS
Don’t:
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Don’t pull stuck clothing off the burn
Don’t put on ointment
Don’t drown your patient
Don’t panic
Thank you
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References & Photos
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Emedicine.com
Tabers Medical Dictionary
BurnSurgery.org
HealthCentral.com
Adam Corporation
Wikipedia.org
Emcert.com
BCAS Protocol Guidelines
Fastlane.com
Healthcentral.com