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This document discusses burn injuries, including their causes, treatment, and effects on the body. It notes that there are about 486,000 burn injuries per year in the US requiring medical attention. The most common causes of burns are fire/flame (43%), scalds (34%), and hot object contact (9%). Burn injuries can impact the skin's ability to regulate temperature, produce vitamin D, and maintain physical identity. Proper fluid resuscitation is especially important for infants and children due to their higher surface area to weight ratio. The document also covers electrical injuries, frostbite, and assessing burn severity and depth.
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- 2. Every year childrenare involved in accidents or born with conditions that require medical care not always available by their local provider.
- 3. • Shriners Hospitalsfor Children® – Cincinnati has experts in the field of burn care, pediatric plastic reconstruction and rehabilitation • Our goal is provide comprehensive services regardless of the patient’s ability to pay
- 4. There are about486,000 burn injuries per year in the US that require medical attention and 3,275 deaths ABA 2016 fact sheet
- 5. Burn Injuries 40,000 of486,000 injuries are hospitalized – 30,000 of those into the 128 burn centers The other 4500 U.S. acute care hospitals average less than 3 burn admissions/year Place of occurrence: 73% home, 8% job, 5% street, 5% recreational, 9% other More males than females burned – 2.5:1 ABA 2016 fact sheet
- 6. Etiology of AdmittedBurns • Fire & flame 43% • Scalds 34% • Hot object contact 9% • Electrical 4% • Chemical 3% • Other 7% ABA 2016 fact sheet
- 7. • Protection 1st lineof defense against infection • Loss of Body Fluids After a burn, large fluid loss occurs • Temperature Regulation Full thickness injuries destroy sweat glands • Sensory Pain, pressure, temperature, and touch Change in sensory perception Skin is largest organ in the body
- 8. • Vitamin Dactivation Skin + sunlight activates vitamin D Partial thickness burns reduce this ability and full thickness burns result in complete loss of ability to activate Vitamin D from the area burned • A person’s Physical identity is closely tied to how their skin looks Self-image issues are common after a burn injury Skin
- 9. • Infants (upto age 1) & children (up to age 15) have a greater surface area per unit of body weight than adults. • Results in greater contact with the environment & greater evaporative water loss per unit of body weight than adults; • Therefore infants & children need more fluid per unit of body weight during resuscitation than adults. Body Surface Area
- 10. • 2 layers •Epidermis • Outer layer • Contains no blood vessels • Healing occurs from the dermal layer underneath the epidermis Anatomy of Skin
- 11. • Thicker thanthe epidermis • Contains blood vessels, sensory nerves, hair follicles, and sweat glands • Healing can occur as long as there is some dermis present after the burn injury Dermis
- 12. • When thewhole dermal layer is destroyed from the burn, the skin can no longer restore itself • Beneath the dermis is subcutaneous fat, muscles, tendons, and bones Dermis
- 13. Types of Burns •Flames • Scalds • Chemicals • Electrical/Lightning
- 14. Flames • House fires •Explosions – gas • Gasoline • Campfires • Fireworks
- 15. Firework Injuries • Consumptionof fireworks has been increasing significantly over recent years with relaxed laws • In 2017, there were 8 deaths from fireworks and 12,900 injuries. Two-thirds happened around the July Fourth holiday. The large majority of the injuries were burns. • Children under 15 years of age experienced about 36 percent of the injuries, and males of all ages were involved in 70 percent. • Insurance Journal: July 2018
- 16. Scald Injuries • Occurwhen the child has a hot liquid spilled on him • How bad the burn will be depends on what the hot liquid is. Example: Water boils at 100C, but soup with chicken fat will boil at a higher temperature so soup will burn deeper faster
- 17. Scald Injuries • Mostscald injuries in children occur while bathing • Most common burn injury in children under 4 years of age • 95% of scalds occur in the residence
- 18. Scald Injuries • Timeof contact and water temperature to cause a burn - 120 degrees – 5 minutes - 130 degrees - 30 seconds - 140 degrees - 5 seconds - 160 degrees - instantaneous • Young children and older adult may burn deeper faster because their skin is often thinner • Set hot water heaters appropriately
- 19. Accidental Scald Burns Splash marks present Irregular pattern of burn Run-down pattern Consistent history
- 20. Identifying Abuse andNeglect • Verify burn history • Assess burn pattern • 60% of burn histories do not match the pattern of injury • The child is pre verbal so they are unable to explain the injury
- 21. Patterns of Injury ClassicAbuse: • Sock-glove like distribution • No splash marks • Symmetrical deep second or third degree burns of the hands or feet
- 22. Chemicals Most common types •Alkalis Home & work: cleaning, hobbies •Acids •Organic compounds – petroleum products
- 23. Treatment • Protect yourself– use PPE • Remove saturated clothing, jewelry, contacts • Brush off powder agents • Continuously irrigate area with copious amounts of water * Neutralizing chemical contraindicated Potential for heat generation * Continue irrigation until pain decreases or patient is evaluated at a burn center
- 24. Treatment • Support ABC’s.Chemical agents can impact respiratory &/or circulatory status • Establish IV access for large chemical injuries • If irrigating a large burn, avoid hypothermia • Identify agent if possible but do not delay therapy until agent is identified • Contact Poison Control Center if needed
- 25. Chemical Injuries toEyes • Alkalis are twice as common as acid injuries • Alkalis bond to tissue protein: require prolonged irrigation • Water or saline irrigation – begin at scene & continue until seen by qualified professional • Consult ophthalmologist
- 26. Anhydrous Ammonia • Seencommonly in fertilizer or industrial refrigerant • Used in the manufacture of methamphetamine • Is a strong base with a penetrating odor – pH 12 • Skin blistering with exposure, eye irritant • If fumes are inhaled Increased secretions combined with sloughed epithelium, necrotic debris, tissue edema & reactive bronchospasm Treat with copious irrigation to wounds; intubate as necessary may need
- 27. Tar Burns • Tarcreates a thermal injury, not a chemical one • Bitumen compound not absorbed, not toxic • Cool tar to stop the burning process • Facilitate removal with use of a petroleum based ointment or medically safe solvent to emulsify the tar
- 28. Electrical Injury: TheGrand Masquerader * Small surface injuries may be associated with devastating internal injuries * Many work related with significant economic impact
- 29. Electrical Injuries • Low-voltage<1,000 V Localized to area surrounding the area • • High-Voltage >1,000 V Deep extension and underlying tissue damage
- 30. The extent ofthe injury is dependent upon… •Type of current - Alternate Current (AC) – 120v, back & forth flow of current; usually contact burn only - Direct Current (DC)– flows in 1 direction; entrance and exit points Usually high voltage •Pathway of flow through body •Local tissue resistance •How long the body is in contact with the electrical source Tissue Injury
- 31. • Bone &skin have high resistance • Once through the skin, the electrical current flows through the tissue under it, especially along bones creating more heat • Heat damages the muscle around it • Deep muscle injury may occur, including compartment syndrome, even when superficial muscle appears normal Tissue Resistance
- 32. Treatment • Scene Safety •Assess Entrance and Exit wounds • Monitor for dysrhythmias • May require increased fluids during resuscitation to flush out myoglobin • NaHCO3 may be considered if myoglobin is present in urine
- 33. Lightning • Over thelast 10 yrs, caused average of 28 deaths/yr. • The spectrum of burn injury varies widely from pt to pt. • Many survivors suffer serious complications related to the cardiac and neurological systems. • Not always associated with deep burns as the current generated from lightning often travels on the surface of the body and not through it. • The cutaneous burns are typically superficial presenting what has been called a “splashed on” spidery pattern.
- 34. Burns From OtherSources • Curling Iron • Irons • Grills • Cigarettes Suspect abuse if you notice several pattern burns
- 36. Frostbite Injury due tointracellular water turning to ice and extreme cold constricting, damaging, and blocking the blood supply to exposed parts. Treatment protocol involves re-warming and care in a specialized treatment unit for wound care
- 37. •Determining the Severityof a Burn
- 38. • Burn severityis based on how much of the body surface area is injured and the depth of the burn • Skin thickness also affects burn depth Young children and older adults tend to have thinner skin, resulting in deeper injuries in these age groups, even when the temperature is lower Depth of Burn Injury
- 39. • Only involvesthe epidermis – also called 1st degree burn • The cells needed for re-growth remain • Caused by prolonged exposure to low intensity heat or short exposure to high intensity heat • Flash burn Superficial Thickness Wounds
- 40. • Reddened, Painful,Mild Swelling • No Blisters • Peeling occurs 2-3 days after the burn • Heals Within 3-6 Days • No Scarring • Care: Lotion or aloe for comfort • Acetaminophen or ibuprofen for mild pain Superficial Thickness Wounds
- 41. • Involves theentire epidermis and varying depths of the dermis – also called 2nd degree burn • Called a superficial partial thickness or deep partial thickness burn depending on how far down into the dermis the injury goes Partial Thickness Wounds
- 42. • Involves theupper third of the dermis • Small vessels bringing blood to this area are damaged, resulting in large amounts of plasma leaking, which is trapped between the dermis and epidermis resulting in a blister • Pink, Moist, Blisters, Swollen, Blanches • Painful because nerve endings are exposed when the blisters are broken • Heals within 2-3 weeks with proper care • No scarring, but pigmentation changes can result and be permanent Superficial Partial Thickness Injuries
- 43.
- 44. • Burn injuryextends in into the lower 2/3 of the dermis • Blisters don’t usually form because the layer of dead tissue is thick, and sticks to the dermis underneath, so does not easily lift off the surface to make the blister • Wound is dryer than a superficial partial thickness injury because fewer blood vessels are left that have not been injured • Often looks red with patches of white • Blanching either occurs slowly or not at all Deep Partial Thickness Injuries
- 45. • Moderate amountsof edema • Less pain than with superficial burns because more of the nerve endings have been destroyed • Can convert to full thickness wounds if there is infection, or poor blood flow to the area because there is further tissue damage • Heals within 2-6 weeks • Skin grafting can reduce healing time and often produces a better looking scar • These burns will scar • Massage and pressure garments will reduce thickness and redness of scars Deep Partial Thickness Injuries
- 46. • Burn injurydestroys the entire epidermis and all of the dermis, leaving no skin cells to regenerate. Also called a 3rd degree burn • Will not heal without grafting • No pain • No blanching • Hard, dry leathery appearance called eschar forms from the destroyed skin • Eschar is dead tissue and must be removed before any healing can occur • If the eschar is not removed, patient can become septic and even die from toxins given off by the eschar Full Thickness Injuries
- 47. • Severe edemais present under the eschar • Circumferential injuries: • Because of the leathery texture of the eschar and the severe edema, blood flow to and movement of the area may be reduced • Escharotomies or fasciotomies may be needed to relieve pressure, allowing normal blood flow Full Thickness Injuries
- 48. • May becalled a 4th degree burn • The burn injury damages muscle, bone, and/or tendons • Looks black and sunken in • All feeling is gone • Amputation may be needed when an extremity is involved Deep Full Thickness Injuries
- 50. • Affects allbody systems • Vascular changes • Circulation to the burned skin is immediately altered • Inflammation that develops causes the blood vessels near the wound to dilate and have increased capillary permeability causing fluids to leak into the interstitial space = “3rd spacing” Initial Clinical Manifestations of Burn Injury
- 51. • Continuous leakof plasma from the vascular space into the interstitial space • Leads to loss of plasma and proteins which decreases blood volume and decreases blood pressure • This leakage occurs in surrounding tissues and may cause edema even in areas not burned • If TBSA is >25%, capillary leak and edema occurs in both burned and unburned areas • This fluid shift occurs within the first 12 hours and continues for 36 hours after burn injury Third Spacing
- 52. • Fluid shiftslead to fluid/electrolyte and acid/base changes • Hypovolemia-3rd spacing • Metabolic acidosis-cell destruction • Hyperkalemia (↑K)-cell destruction releases large amounts of potassium (K) • Hyponatremia (↓Na) - 3rd spacing • Sodium stays in the body but it is in the interstitial space, not the vascular system Third Spacing con’t …
- 53. • Increased hemoglobinand hematocrit • Vascular dehydration- the volume is outside the blood vessels in the 3rd space • Problem as it increases blood viscosity, decreases general blood flow throughout the body and increases tissue hypoxia Hemoconcentration from Fluid Shift
- 54. • Capillary leakstops • Amount of edema seen on the outside is matched in the airway and pulmonary system 24-36 Hours After Injury
- 55. • Tachycardia • Decreasedcardiac output because of fluid shifts and hypovolemia initially • May improve with fluid resuscitation • Proper resuscitation and administration of oxygen helps prevent complications Cardiac
- 56. • Direct lunginjury from flames rarely occurs • Superheated air, steam, toxic fumes, and smoke can cause respiratory injury • Respiratory issues are the major cause of death in burn patients and much more likely to happen when the injury occurred indoors e.g. trailers • Difficult to have inhalation injury with an outdoor fire Respiratory
- 57. • Inhalation injuriescan occur in upper airway, major airways, and lung tissue • Upper airway- inhaled smoke or irritants cause edema and blocks the trachea • Inflammatory response results in edema of throat and mouth with possible airway obstruction • Same level of edema seen on outside is also in the airway • Worsens with fluid resuscitation but it is necessary Respiratory
- 58. • Toxic irritants( chemicals & gases) can damage the lung tissue including alveoli and capillaries • Leaking capillaries in the lungs can cause alveolar edema which leads to decreased oxygen exchange • The leaking fluids contain protein which forms fibrinous membranes and leads to respiratory distress and pulmonary failure • Smoke and gases also slow the ciliary activity allowing particles to enter the bronchi • Lining of trachea and bronchi may slough at 48-72 hours after injury and obstruct the lower airway Respiratory
- 59. Effects of Edemaon Airway Resistance in the Infant versus the Adult Infant Adult Normal Edema 1mm Resistance increase Diameter Decrease 16x 3x 75% 44%
- 60. • As respiratoryfailure can follow, endotracheal intubation or tracheostomy is sometimes needed to maintain an open airway • Chest burns with eschar can restrict chest movement • Carbon monoxide poisoning Respiratory
- 61. • Reduced cardiacoutput and fluid shifts decrease blood flow to the GI tract • Impairs gastric motility and stress can cause a gastro-duodenal ulcer called a Curlings ulcer • At worst, destroys sections of the intestine • As peristalsis decreases an ileus may develop • Secretions and gases collect in GI tract causing abdominal distention GI Changes
- 62. • Increased metabolism •Oxygen use and caloric needs are high • Caloric needs may double and cause catabolic activity • **Can remain elevated even months after all wounds are healed • Increases core body temperature: Lose heat through burned areas and the body tries to heat the body to maintain equilibrium, often resulting in low-grade fever Metabolic Changes
- 63. • Diuretic phase-fluid goes back from the interstitial space into the vascular space • Blood volume increases leading to ↑ blood flow to kidneys and diuresis occurs • Hyponatremia continues- now because the kidneys are excreting the sodium • Hypokalemia- potassium moving back into cells and excreted in urine • Sodium & potassium will need to be replaced by IV • Protein continues to be lost from the wounds • Metabolic acidosis due to ↑ metabolic rate & loss of bicarbonate in the urine 48-72 Hours After Burn Injury
- 64. 1. Safety 2. Stopthe Burning Process 3. Primary Survey and Support – Airway - maintain airway with cervical-spine control – Breathing - assess and support (Oxygen) – Circulation -assess, support, control external hemorrhage, monitor ECG; begin fluid replacement – Disability - evaluate neurologic status (AVPU Method- alert, responds to verbal, pain, unresponsive) – Exposure - Allow for detailed exam Primary Survey of Burn Patient
- 65. Predisposing Factors • Closedspace Physical Examination • Facial burns, singed nasal hairs • Mucosal edema of nose and mouth • Carbonaceous (black) sputum • Hoarseness, strider (laryngeal) • Difficulty breathing, wheezing (small airway) • Decreased level of consciousness Airway & Breathing Assessment for Inhalation Injury
- 66. • Non-Rebreather mask •Bag-Valve Mask Assist – bag patient • Intubation Oxygen
- 67. • Assessment Findings •Absent or poor respiratory effort • Absent peripheral pulses (Central pulse is weak or strong) • Unconscious • Elective vs. Emergent is preferred Intubation
- 68. Carbon Monoxide • ColorlessOdorless Gas • 200x Affinity for Hemoglobin • Does not allow for O2 transport Treatment for CO Poisoning is removal from source, followed by 100% O2.
- 69. • Monitor HeartRate, Pulses, Color, Capillary Refill, O2 level, bleeding • IV’s – large bore IV (2 if a large burn) – through unburned skin if possible but can use burned skin • Pre-hospital amounts before TBSA is calculated: 5 yrs & younger: 125ml Lactated Ringers (LR)/hr 6-13 yrs: 250ml LR/hr 14 yrs & older: 500ml LR/hr Circulation
- 70. Disability • Level ofconsciousness: A burn injury, even 100% will not render a victim unconscious • If the patient is unconscious or incoherent, look for a cause other than the burn. • Heart Attack • Anoxia • Stroke • Head Injury • Pain levels • Glascow scale; APVU to determine LOC
- 71. • Quick Headto Toe examination without clothes – strip & flip • Temperature control • Clean dry dressings Exposure
- 72. Exposure Wet vs. DryDressing? • Always place in dry clean dressings. • Topicals antibiotics are not necessary if being transferred to a burn facility • Ice and cold is absolutely not applied! It causes vasoconstriction to an area that already has poor blood flow
- 73. One of themajor functions of the skin is temperature regulation. If the skin is damaged the body cannot maintain this function. Hypothermia can result. Temperature Regulation
- 74. • Temperature Regulationin infants and children, is affected by their relatively greater body surface area so body heat is lost quickly. (Cover head also!) • Heat generation by shivering is hard for children due to their relatively small muscle mass. • Temperature regulation in infants < 6 months old depends less on shivering and more on the body’s metabolic processes and the air temperature around them. Temperature Regulation
- 75. • Increased fluidneeds • Clotting factors are inhibited • End Organ Perfusion is decreased • DEATH Complications of Hypothermia
- 76. The secondary surveydoes not begin until the primary survey is completed Secondary Survey
- 77. • History, burningagent & location of injury, associated trauma • Medical history – AMPLET (allergies, medications, previous illnesses, last meal, events related to injury, tetanus & immunizations • Accurate pre-burn patient weight • Complete Head to Toe Evaluation • Severity & depth of burn Secondary Survey
- 78. • TBSA involved* •Adjusted fluid rates after TBSA determined* • Monitor fluid resuscitation & urine output* • Obtain labs & x-rays as needed • Pain & anxiety management* • Psychosocial support • Wound Care* Secondary Survey