Transcript Most often caused by strong acids or alkalis. Unlike thermal burns

DR BABAK MASOUMI
ASSISTANT PROFESSOR OF
EMERGENCY MEDICINE
ESFAHAN UNIVERSITY
of MEIDCAL SCIENCES
2011
Superficial
Superficial partial-thickness
Deep partial-thickness
Full-thickness
Very painful, dry, red burns which blanch with pressure. They usually
take 3 to 7 days to heal without scarring. Also known as first-degree
burns. The most common type of first-degree burn is sunburn. Firstdegree burns are limited to the epidermis, or upper layers of skin.
Very painful burns sensitive to temperature change and air exposure.
More commonly referred to as second-degree burns. Typically, they
blister and are moist, red, weeping burns which blanch with pressure.
They heal in 7 to 21 days. Scarring is usually confined to changes in
skin pigment.
Blistering or easily unroofed burns which are wet or waxy dry, and are
painful to pressure. Their color may range from patchy, cheesy white to
red, and they do not blanch with pressure. They take over 21 days to
heal and scarring may be severe. It is sometimes difficult to differentiate
these burns from full-thickness burns.
Burns which cause the skin to be waxy white to a charred black
and tend to be painless. Healing is very slow, if at all, and may
require skin grafting. Severe scarring usually occurs.
The skin, the largest organ of the body, consists of two layers-the epidermis
and dermis. The depth or degree of burn depends on which layers of skin are
damaged or destroyed. The epidermis is the outer layer that forms the
protective covering. The thicker or inner layer of the dermis contains blood
vessels, hair follicles, nerve endings, sweat and sebaceous glands. When the
dermis is destroyed, so are the nerve endings that allow a person to feel pain,
temperature, and tactile sensation.
The most important function of the skin is to act as a barrier
against infection. The skin prevents loss of body fluids, thus
preventing dehydration. The skin also regulates the body
temperature by controlling the amount of evaporation of fluids
from the sweat glands. The skin serves a cosmetic effect by
giving the body shape.
When the skin is burned, these functions are impaired or lost
completely. The severity of the skin injury depends upon the
size of the injury, depth of the wound, part of the body injured,
age of the patient, and past medical history. Because of the
importance of the skin, it becomes clear that injury can be
traumatic and life threatening. Recovery from burn injury
involves four major aspects: burn wound management,
physical therapy, nutrition, and emotional support.
The rule of nines
• The rule of nines is a practical technique for estimating
the extent of TBSA involved in a burn injury.
• This approach divides the major anatomic areas of the
body into percentages of TBSA.
• For the adult, it allots 9% of the TBSA to the head and
neck and to each upper extremity, 18% each to the
anterior and posterior portions of the trunk, 18% to
each lower extremity, and 1% to the perineum and
genitalia.
• The area of a patient's palm represents approximately
1% of the TBSA and can be helpful in calculating
scattered areas of involvement.
The rule of nines
• The primary difference between the
TBSA of the adult and infant reflects the
size of the infant's head (18%), which is
proportionally larger than that of the
adult ,and the lower extremities (14%),
which are proportionately smaller than
those of the adult.
Categorization of Patients
• The severity of a burn injury depends on the
(1) extent, depth. and location of the burn injury;
(2) age of the patient;
(3) etiologic agents involved;
(4) presence of inhalation injury;
(5) coexisting injuries or preexisting illnesses.
• This classification creates three categories of burn
injury (major, moderate. and minor) and defines the
optimal setting for themanagement of each.
Major burn injury
(1) partial-thickness burns involving more than 25% of
TBSA in adults or 20% of TBSA in children younger
than 10 and adults older than 50;
(2) full-thickness burns involving more than 10% of
TBSA;
(3) burns involving the face, eyes. ears. hands. feet, or
perineum that may result in functional or cosmetic
impairment;
(4) burns caused by caustic chemical agents;
(5) high-voltage electrical injury;
(6) burns complicated by inhalation injury or major
trauma; and
(7) burns sustained by high-risk patients (e.g.. those
with underlying debilitating diseases).
Major burn injury
• These injuries are best managed in a
specialized burn center staffed by a team of
professionals with expertise in the care of
burn patients, including both acute care and
rehabilitation.
Moderate burn injury includes
(1) partial-thicknessof 15% to 25% of TBSA in adults or
10% to 20% of TBSA in children and older adults.
(2) Fullthickness burns involving 2% to 10% of TBSA
that do not present a serious threat of functional or
cosmetic impairment of the eyes, ears. face, hands.
feet, or perineum.
The moderate category excludes high-voltage
electrical injury. all burns complicated by inhalation
injury or other trauma. and burns sustained by highrisk
patients.
Moderate burn injury includes
Patients with moderate burn injurie
should be hospitalized for their
initial care but not necessarily at a
burn center.
Minor burn injury
(1) partial-thickness burns involving less than
15% of TBSA in adults or 10% of TBSA in
children and older adults.
(2) fullthickness burns involving less than 2% of
TBSA that do not present a serious threat of
functional or cosmetic risk to eyes. ears. face.
hands. feet. or perineum.
These burns can usually be managed safely in
the outpatient setting.
1. Treatment should begin immediately to cool the
area of the burn. This will help alleviate pain.
2. For deep partial-thickness burns or fullthickness burns, begin immediate plans to
transport the victim to competent medical care.
For any burn involving the face, hands, feet, or
completely around an extremity, or deep burns;
immediate medical care should be sought. Not
all burns require immediate physician care but
should be evaluated within 3-5 days.
3. Remove any hot or burned clothing.
Are you one of those people that stays up to date on
the latest sports scores and plays?
Improper use, handling, and
storage of hazardous
materials can lead to a
different type of scoring…
it’s called burn scoring
which measures the
percentage of the body
burned. The score you rate
on this chart can last you a
lifetime.
4. Use cool (54 degree F.) saline solution to cool the area for 15-30
minutes. Avoid ice or freezing the injured tissue. Be certain to
maintain the victim’s body temperature while treating the burn.
5. Wash the area thoroughly with plain soap and water. Dry the area
with a clean towel. Ruptured blisters should be removed, but the
management of clean, intact blisters is controversial. You should
not attempt to manage blisters but should seek competent medical
help.
6. If immediate medical care is unavailable or unnecessary, antibiotic
ointment may be applied after thorough cleaning and before the
clean gauze dressing is applied.
Scalding-typically result from hot water, grease,
oil or tar. Immersion scalds tend to be worse than
spills, because the contact with the hot solution is
longer. They tend to be deep and severe and should
be evaluated by a physician. Cooking oil or tar
(especially from the “mother pot”) tends to be fullthickness requiring prolonged medical care.
a. Remove the person from the heat source.
b. Remove any wet clothing which is retaining heat.
c. With tar burns, after cooling, the tar should be
removed by repeated applications of petroleum
ointment and dressing every 2 hours.
Looks and tastes great,
right? You should see what
a hot liquid will do to a
child’s skin when the two
come into contact.
Be sure to keep
hot liquids out of
reach of small
children.
Flame
a. Remove the person from the source of the heat.
b. If clothes are burning, make the person lie down to keep
smoke away from their face.
c. Use water, blanket or roll the person on the ground to
smother the flames.
d. Once the burning has stopped, remove the clothing.
e. Manage the persons airway, as anyone with a flame burn
should be considered to have an inhalation injury.
Electrical burns: are thermal injuries resulting
from high intensity heat. The skin injury area
may appear small, but the underlying tissue
damage may be extensive. Additionally, there
may be brain or heart damage or musculoskeletal
injuries associated with the electrical injuries.
a. Safely remove the person from the source of the
electricity. Do not become a victim.
b. Check their Airway, Breathing and Circulation
and if necessary begin CPR using an AED
(Automatic External Defibrillator) if available and
EMS is not present. If the victim is breathing,
place them on their side to prevent airway
obstruction.
c. Due to the possibility of vertebrae injury
secondary to intense muscle contraction, you
should use spinal injury precautions during
resuscitation.
d. Elevate legs to 45 degrees if possible.
e. Keep the victim warm until EMS arrives.
Chemical burns- Most often caused by strong
acids or alkalis. Unlike thermal burns, they can cause
progressive injury until the agent is inactivated.
a. Flush the injured area with a copious amount of water
while at the scene of the incident. Don’t delay or waste
time looking for or using a neutralizing agent. These
may in fact worsen the injury by producing heat or
causing direct injury themselves.
Perform an ABCDEF
primary survey
•
•
•
•
•
•
A—Airway with cervical spine control
B—Breathing
C—Circulation
D—Neurological disability
E—Exposure with environmental control
F—Fluid resuscitation
Yes
Airway
Intubate
Compromised or at
risk of compromise?
Cause:
No
Mechanical
Carboxyhaemoglobin
Smoke inhalation
Breathing
Compromised?
Yes
No
Circulation
Compromised perfusion
to an extremity?
Blast injury
Yes
Escharotomies
Intubate and ventilate
Nebulisers
Non-invasive ventilation
Invasive ventilation
Invasive ventilation
Chest drains
Escharotomies
No
Neurological Disability
Impaired score on
Glasgow coma scale?
Yes
No
Consider:
Hypoxia (carboxyhaemoglobin level?)
Hypovolaemia
Traumatic brain injury
Exposure
Fully assess burn area and depth
Full examination for concomitant injuries
Keep warm
Fluids
Calculate resuscitation formula based on
surface area and time since burn
Initial burn management in ED
•
•
•
•
•
•
•
Assess burn size and depth
Establish good IV access and give fluids
Give analgesia
Place NG tube and Foley catheter
Take baseline blood samples
Dress wound
Perform secondary survey, reassess, and
exclude or treat associated injuries
• Arrange safe transfer to specialist burns
facility
Airway Management
• The natural history of upper airway burn injury
is the development of edema that narrows the
airway 12 to 24 hours after injury.
• The tongue and oral mucosa become edematous
much more quickly, within minutes to hours.
• Consequently, intubation rather than
observation is recommended in patients with
signs of upper airway injury, such as stridor,
inspiratory grunting.wheezing, or tachypnea.
Airway Management
• Fiberoptic bronchoscopy is a simple. safe, and
accurate method of diagnosing acute
inhalation injury.
• If the respiratory insufficiency is caused by a
constricting eschar of the anterior thorax that
limits respiratory excursion, escharotomy is
imperative.
CO Poisening
• CO is present in smoke, and its affinity for
hemoglobin is 280 times that of oxygen.
• A CO level is obtained for all patients with
suspected inhalation injury.
• Patients should receive 100% oxygen until
their carboxyhemoglobin (COHb)level is less
than 10% because the elimination half-life of
COHb depends on oxygen tension.
CO Poisening
• In room air, the half-life of CO-bound
hemoglobinis 4 hours.
• Under 100% oxygen, the half-life of CObound hemoglobin decreases to 45 minutes.
• Administration of 100% oxygen increases the
gradient for oxygen binding to hemoglobin,
and unbound CO is exhaled through the
lungs.
Cyanide Poisoning
•Specific therapy for cyanide poisoning in patients
with inhalation injury is another consideration.
•Cyanide causes tissue hypoxia by uncoupling
oxidative phosphorylation by binding to
mitochondrial cytochrome.
•Empirical treatment for cyanide toxicity should
be considered for patients with unexplained severe
metabolic acidosis associated with elevated central
venous oxygen content, normal arterial oxygen
content, and a low COHb level.
Circulation
• Patients with moderate burns should have
at least one large-bore IV line placed
through unburned skin, and those with
severe burns should have at least two lines
initiated.
• When a burn patient requires considerable
fluid resuscitation or has evidence of
cardiopulmonary disease, a central venous
line is indicated.
Circulation
• The microvascular injury caused by a burn
produces increased vascular permeability with
edema formation that results in ongoing
plasma volume loss.
• Maximal edema formation occurs 8 to 12 hours
after injury for small burns and 24 hours after
injury for large burns.
• The purpose of fluid resuscitation is to restore
effective plasma volume, avoid microvascular
ischemia, and maintain vital organ function.
Circulation
• The amount of fluid required varies with
the patient's age, body weight, and extent
of TBSA burned.
• Typically, burns greater than 20% of
TBSA require IV fluid resuscitation
because the accompanying
gastrointestinal ileus precludes sufficient
oral intake.
Circulation
• Although different formulas for fluid
resuscitation have been recommended, all
regimens emphasize that adequate
resuscitation is evidenced by a normal
urine output
• 1 mL/kg/hr in children younger than 2
years,
• 0.5 mL/kg/hr in older children,
• At least 30 to 40 mL/hr in adults,
• A normal sensorium, and stable vital signs.
Circulation
• The Parkland formula for fluid
resuscitation of burn patients is used as
follows:
LR solution (4 mL/kg/% TBSA burned) is
administered intravenously in the first 24
hours, with one half given in the first 8
hours and the other half over the next 16
hours.
Circulation
• The percent TBSA used for the formula
includes only second- and third-degree
burn injuries.
• The fluid loss must be calculated from
the time of injury.
• Fluid replacement must take into
account the fluid administered
prehospital personnel.
Circulation
• To avoid overhydration, patients with
inhalation injuries should be resuscitated with
substantially less than formula predictions,
with acceptance of a urinary output in the
range of 0.3 to 0.5 mUkg/hr.
Circulation
• When endothelial integrity is restored 24 hours
after the injury, some clinicians favor the
administration of 5% albumin at 0.5 mL/kg/%
TBSA to maintain dynamic forces between the
extracellular spaces and the intravascular
system. In addition, a low dose
• Dopamine infusion (3 to 5 µg/kg/min) is beneficial
in restoring renal and splanchnic blood flow in
patients with major burn injury.
Circulation
• Hypertonic saline resuscitation has been
associated with an increased occurrence of
acute tubular necrosis and hyperchloremic
metabolic acidosis, which can exacerbate
the metabolic acidosis of hypovolemic
shock.
• Therefore, hypertonic saline is not
currently recommendedfor resuscitation of
burn.
Analgesia
• All patients with large burns should
receive intravenous morphine at a dose
appropriate to body weight.
• The need for further doses should be
assessed within 30 minutes.
Wound management
• Estimating surface area and depth of a burn.
• Washing the wound and removing any loose skin.
• Deroofing the blisters for ease of dressing, except for
palmar & Soles blisters.
• Cover the wounds with sterile moist saline dressings.
• If disposition is delayed, , cleanse with sterile saline,
Apply topical antibacterial agent (e.g., silver
sulfadiazine, bacitracin, or mafenide acetate).
• Prophylactic antibiotics not indicated
• Tetanus toxoid or immunoglobulin: 0.5 mL IM; 250 U
IM once along with toxoid .
Criteria for referral to a
burns centre
• Associated airway injury
• Partial thickness burns >5% of total body surface area
in a child
• Partial thickness burns >10% of total body surface
area in an adult >1% full thickness burn
• Partial or full thickness burns to face, perineum,
external genitalia, feet and hands, and over joints
• Circumferential injury
• Chemical and electrical burns
• Extremes of age
• Intentional injury
• Comorbidity
Key points
• Perform a systematic assessment as with any
trauma patient (don’t get distracted by the
burn)
• Beware of airway compromise
• Provide adequate analgesia
• Exclude any concomitant injuries
• Discuss with a burns unit early
• If in doubt, reassess
question?