Burn Injury

May 2009 CEMay 2009 CE

Condell Medical Center EMS System Condell Medical Center EMS System

Prepared by: FF/PM Michael MountsPrepared by: FF/PM Michael Mounts

Lake Forest Fire DepartmentLake Forest Fire Department

Reviewed/revised by: Sharon Hopkins, RN, BSN, EMTReviewed/revised by: Sharon Hopkins, RN, BSN, EMT--PP

Objectives

�� Identify the different functions of the Identify the different functions of the integumentary system (skin) integumentary system (skin)

�� Identify the different layers of the Identify the different layers of the integumentary system and how they are integumentary system and how they are affected by each burn classification.affected by each burn classification.affected by each burn classification.affected by each burn classification.

�� Identify Total Body Surface Area (TBSA) of Identify Total Body Surface Area (TBSA) of burn following the “Rule of Nines” method.burn following the “Rule of Nines” method.

�� Identify the different classifications of burns Identify the different classifications of burns when given a photo or signs & symptoms of when given a photo or signs & symptoms of that injury.that injury.

�� Identify the different types of burn injury, i.e. Identify the different types of burn injury, i.e. thermal, chemical, electrical, & inhalation.thermal, chemical, electrical, & inhalation.

Objectives cont.

�� Identify abuse/neglect casesIdentify abuse/neglect cases

�� Identify assessment techniques Identify assessment techniques

�� Identify Region X SOP for burn injuriesIdentify Region X SOP for burn injuries

�� Identify fluid resuscitation guidelines Identify fluid resuscitation guidelines �� Identify fluid resuscitation guidelines Identify fluid resuscitation guidelines (Parkland Formula)(Parkland Formula)

�� Review proper wound care with dressing Review proper wound care with dressing application for burns application for burns

�� Return demonstrate use of the IO drill for Return demonstrate use of the IO drill for the adult and pediatric patientsthe adult and pediatric patients

Burns

Burn Incidence

�� More than 1 million burn injuries per yearMore than 1 million burn injuries per year

�� 45,000 hospitalizations per year 45,000 hospitalizations per year

�� Half go to one of the 125 specialized burn centersHalf go to one of the 125 specialized burn centers

The other half go to the nations 5000 other The other half go to the nations 5000 other �� The other half go to the nations 5000 other The other half go to the nations 5000 other hospitalshospitals

�� 4500 fire and burn deaths per year 4500 fire and burn deaths per year

�� 3750 burns from fire3750 burns from fire

�� 750 (burns from MVC, electrical, chemical, 750 (burns from MVC, electrical, chemical, scald, other)scald, other)

Severity of Burn

�� Severity of burn determined by depth, size, Severity of burn determined by depth, size, and locationand location

�� Average TBSA (Total Body Surface Area) Average TBSA (Total Body Surface Area) admitted to a burn center is 14%admitted to a burn center is 14%

�� Overall percentage of the TBSA is on the Overall percentage of the TBSA is on the declinedecline

�� About 6% of Burn Center About 6% of Burn Center Admissions do not surviveAdmissions do not survive

Pediatric Problems

�� 35% of all burn injuries occur in children35% of all burn injuries occur in children

�� 85% of pediatric burns are toddler aged85% of pediatric burns are toddler aged

��From one to three years of ageFrom one to three years of age��From one to three years of ageFrom one to three years of age

�� 2,500 children die from thermal injury2,500 children die from thermal injury

�� 10,000 suffer severe permanent disability10,000 suffer severe permanent disability

�� Second leading cause of accidental death in Second leading cause of accidental death in

childrenchildren

Seasonal Injuries

�� Summer (BBQ, Summer (BBQ,

automobiles)automobiles)

�� Fall (burning leaves Fall (burning leaves

& brush, turkey & brush, turkey

fryers)fryers)fryers)fryers)

�� Winter (house fire Winter (house fire

& alternative & alternative

heating)heating)

�� Spring (similar to Spring (similar to

fall)fall)

�� Skin is the largest, most important organSkin is the largest, most important organ

�� 16% of total body weight16% of total body weight

Function of the Skin

�� FunctionFunction

��ProtectionProtection

��SensationSensation

��Temperature regulationTemperature regulation

�� Aka: Integumentary systemAka: Integumentary system

Body Temperature Regulation

�� Loss of the integrity Loss of the integrity

of the skin results in of the skin results in

the loss of the loss of

evaporative & heat evaporative & heat evaporative & heat evaporative & heat

barriersbarriers

�� Body heat is lost byBody heat is lost by

��ConvectionConvection

��ConductionConduction

��RadiationRadiation

Anatomy & Physiology of Skin

�� Skin LayersSkin Layers

��EpidermisEpidermis

��Social function Social function –– visible part of bodyvisible part of body

��Outmost, avascular layer of dead cellsOutmost, avascular layer of dead cellsOutmost, avascular layer of dead cellsOutmost, avascular layer of dead cells

��Helps protect body from bacteria & Helps protect body from bacteria & toxins from the environmenttoxins from the environment

��Prevents excessive water lossPrevents excessive water loss

��Sebum Sebum –– waxy surface lubricantwaxy surface lubricant

��Neurosensory function Neurosensory function –– touch, pain, touch, pain, pressure, sensationpressure, sensation

A & P of Skin cont’d

�� DermisDermis�� Controls body temperature & provides Controls body temperature & provides

flexibilityflexibility

�� Upper layer (papillary layer)Upper layer (papillary layer)

�� Loose connective tissue, capillaries and Loose connective tissue, capillaries and nervesnervesnervesnerves

�� Lower layer (reticular layer)Lower layer (reticular layer)

�� Integrates dermis with subcutaneous layerIntegrates dermis with subcutaneous layer

�� Blood vessels, nerve endings for touch & pain, Blood vessels, nerve endings for touch & pain, hair follicles, & glandshair follicles, & glands

�� Sebaceous & sudoriferous glandsSebaceous & sudoriferous glands

�� Burns into dermis are considered significantBurns into dermis are considered significant

�� Healing occurs if the dermal layer is presentHealing occurs if the dermal layer is present

A & P of Skin cont’d

�� Subcutaneous layerSubcutaneous layer

��Adipose tissueAdipose tissue

•• Tissue that contains stored fatTissue that contains stored fat•• Tissue that contains stored fatTissue that contains stored fat

��Heat retention Heat retention

Normal Skin Cross-section

�� Damaged skin Damaged skin

crosscross--sectionsection

��Note Note

differences differences

between between

levels of levels of levels of levels of

injuryinjury

Depth Determination/Severity

�� Burning substanceBurning substance

�� TemperatureTemperature

�� Duration of Duration of �� Duration of Duration of exposureexposure

�� Location of bodyLocation of body

�� Age of the patientAge of the patient

�� Initial care of the Initial care of the burn providedburn provided

Adult Rule of Nines

Infant Rule of Nines

�� Notice the larger % Notice the larger % for their headfor their head

�� 18% for the entire 18% for the entire anterior thorax anterior thorax including chest and including chest and including chest and including chest and abdomenabdomen

�� Posterior area often Posterior area often broken into 13% for broken into 13% for back and 2.5% for back and 2.5% for each buttock cheekeach buttock cheek

Rule of Palms

�� An alternate system for approximating the An alternate system for approximating the extent of the burnextent of the burn

��Especially helpful in small, local burns Especially helpful in small, local burns

�� The patient’s palm minus fingers represents The patient’s palm minus fingers represents �� The patient’s palm minus fingers represents The patient’s palm minus fingers represents approximately 1% of their total body approximately 1% of their total body surface areasurface area

�� Can be used for all persons; all agesCan be used for all persons; all ages

�� Must use the patient’s palm, not yoursMust use the patient’s palm, not yours

�� Need to visualize the palmar surface and Need to visualize the palmar surface and apply that to the injured areaapply that to the injured area

Patient’s burn area is

re-calculated at burn

unit using this chart

More accurate than Rule of Nines

*Note –

Patient’s palm = 1%

Burn Classifications

�� SuperficialSuperficial

��First Degree First Degree

�� Partial Thickness Partial Thickness �� Partial Thickness Partial Thickness

��Second DegreeSecond Degree

�� Third DegreeThird Degree

��Full ThicknessFull Thickness

Revised Burn Nomenclature

Superficial Burns

�� Involves only the epidermisInvolves only the epidermis

�� Think sunburn: Think sunburn:

��RedRed��RedRed

��DryDry

��Often painfulOften painful

�� Heals is less than one week without scarringHeals is less than one week without scarring

Superficial Burns cont.

�� Red, dry skinRed, dry skin

�� Handprint showing Handprint showing �� Handprint showing Handprint showing

that he won’t be that he won’t be

modeling anytime modeling anytime

soon soon

Partial Thickness Burns

�� Involves entire epidermis Involves entire epidermis

and part of the dermisand part of the dermis

�� Skin is red, blistered, Skin is red, blistered, �� Skin is red, blistered, Skin is red, blistered,

swollen and wetswollen and wet

��PAINFUL!!PAINFUL!!

�� Superficial heals 10Superficial heals 10--12 12

days without scarringdays without scarring

Partial Thickness Burns cont.

�� Red, wet, blistering, peeling, skinRed, wet, blistering, peeling, skin

�� PAINFUL!PAINFUL!

Partial

Thickness

Burns

�� Boiling waterBoiling water

�� Hot glue gun 145Hot glue gun 14500C C

( 318( 31800F)F)

�� Scald burnScald burn

Full Thickness Burns

�� Involves entire Involves entire

epidermis and dermisepidermis and dermis

�� May extend into May extend into

underlying structuresunderlying structuresunderlying structuresunderlying structures

�� Wounds are DRY, Wounds are DRY,

charred, white, leathery, charred, white, leathery,

or waxyor waxy

�� May also see coagulated May also see coagulated

blood vesselsblood vessels

Full Thickness Burns cont.�� White, waxy appearanceWhite, waxy appearance

�� Does not blanch to pressureDoes not blanch to pressure Non Burned

Area

PATIENTS may STILL HAVE

PAIN!!

BECAUSE...BECAUSE...

Third degree burns are usually Third degree burns are usually Third degree burns are usually Third degree burns are usually

surrounded by first and second surrounded by first and second

degree burns!degree burns!

Eschar

�� Dead skinDead skin

�� LeatheryLeathery

�� Dangerous potentials:Dangerous potentials:

Compartment Compartment ��Compartment Compartment syndromesyndrome

��Chest restrictionChest restriction

��Subeschar edemaSubeschar edema

�� Patient will need Patient will need graftinggrafting

Local Tissue Response to Burn

Injury

�� Jackson’s Theory of Thermal WoundsJackson’s Theory of Thermal Wounds

��33--Dimensional model showing burn Dimensional model showing burn

depth and TBSA burneddepth and TBSA burneddepth and TBSA burneddepth and TBSA burned

�� 3 Zones of Injury3 Zones of Injury

��Zone of CoagulationZone of Coagulation

��Zone of StasisZone of Stasis

��Zone of HyperemiaZone of Hyperemia

Jackson’s Thermal Wound Theory

�� Zone of coagulationZone of coagulation

�� Area nearest the burnArea nearest the burn

�� Ruptured cell membranes, clotted blood and Ruptured cell membranes, clotted blood and

thrombosed vesselsthrombosed vessels

�� Zone of stasisZone of stasis�� Zone of stasisZone of stasis

�� Area surrounding zone of coagulationArea surrounding zone of coagulation

�� Inflammation, decreased blood flowInflammation, decreased blood flow

�� Zone of hyperemiaZone of hyperemia

�� Peripheral area of burnPeripheral area of burn

�� Limited inflammation, increased blood flowLimited inflammation, increased blood flow

Types of Burn Injury

�� ThermalThermal

�� Chemical Chemical

�� ElectricalElectrical

�� InhalationInhalation

��Note:Note: Following each burn type, Following each burn type,

there are pictures showing examples. there are pictures showing examples.

Some pictures are quite graphic!Some pictures are quite graphic!

Types of Burn Injury cont.

�� Thermal Thermal -- Damage to tissues from exposure Damage to tissues from exposure

to heat and/or flameto heat and/or flame

��Scald Scald

FlameFlame��FlameFlame

��Thermal contactThermal contact

�� 2 day old scald by hot radiator fluid2 day old scald by hot radiator fluid

�� What would you do in the field for the What would you do in the field for the blister?blister?

��Leave it intact Leave it intact –– it acts as a protective it acts as a protective dressingdressing

Patient upon arrival

on unit

With torso burns

and possible airway

involvement, involvement,

patient mortality is

high

What concerns

would EMS have in

the field?

Non-burned area

Scald Burn – Partial thickness on back and arms

Full thickness from waist down

Deep fryer

pulled off

counter

Full thicknessFull thickness

*Note swelling

to face

Flame Burn

Full & Partial thickness

Full thickness with partial around edge. Deep partial

thickness may heal in 2-3 months with severe scarring.

Thumb and fingers are full thickness

Full thickness – only area not burned is under thigh (pink area)

*Note – Hand burns at top of picture

Full thickness to abdomen inner thigh and breast

Tar Burns

�� Treat tar burns as thermal burnsTreat tar burns as thermal burns

�� Immediately cool the burn with large Immediately cool the burn with large amounts of wateramounts of water

�� Due to the extremely high temperatures and Due to the extremely high temperatures and the solidifying of the tar on contact, the the solidifying of the tar on contact, the the solidifying of the tar on contact, the the solidifying of the tar on contact, the burns are usually very severeburns are usually very severe

�� Neosporin ointment or sunflower oil are Neosporin ointment or sunflower oil are dispersing agents that help with removal of dispersing agents that help with removal of tar from burnstar from burns

�� This would be performed in the EDThis would be performed in the ED

Chemical Burns

�� Often occupationalOften occupational

�� May occur secondary May occur secondary to assaultto assault

�� Acid/alkali or Acid/alkali or petroleum distillatepetroleum distillatepetroleum distillatepetroleum distillate

�� Severity depends uponSeverity depends upon

�� Agent & Agent & concentrationconcentration

�� VolumeVolume

�� Duration of Duration of exposureexposure

Treatment Principles for Chemical

Burns

�� Alkalis should be flushed for a minimum of Alkalis should be flushed for a minimum of 15 minutes15 minutes

�� Acid exposures should be flushed for a Acid exposures should be flushed for a minimum of 5 minutesminimum of 5 minutesminimum of 5 minutesminimum of 5 minutes

�� Unknown exposures should be flushed for Unknown exposures should be flushed for 20 minutes20 minutes

�� When flushing eyes, turn the head to the When flushing eyes, turn the head to the side, raise the eyelid off the eyeball to flush side, raise the eyelid off the eyeball to flush contents trapped under the lidcontents trapped under the lid

�� Do not delay transport to continue flushingDo not delay transport to continue flushing

Chemical burn to arms, torso & legs

*Note – NOT burned around pectoral & belly

Non-burned

areas

Chemical burn – burning to legs & feet around

laces of work boot (same pt as previous slide)

Chemical burn to thigh

*Note drip marks near the top

Battery acid poured on car seat –

prolonged contact increases the injury

Sources Electrical Burn

�� Low voltage injuryLow voltage injury

�� High voltage injuryHigh voltage injury

�� Lightning injuryLightning injury

Electrical burn of mouth

Electrical Burn Injuries

�� Entrance and Exit wounds can differ Entrance and Exit wounds can differ greatly in appearance and severitygreatly in appearance and severity

�� Most of the damage is done upon exit Most of the damage is done upon exit �� Most of the damage is done upon exit Most of the damage is done upon exit of the energy and within the tissues it of the energy and within the tissues it passespasses

��The next three slides are of the same The next three slides are of the same patient.patient.

Electrical entry wound

Partial to full thickness

*Note – electrical burns between entry and exit wound, work from the inside to the outside

Electrical exit

wound

Lightning Strikes

�� If you hear it, clear it!If you hear it, clear it!

�� If you see it, flee it!If you see it, flee it!

�� The threat of lightning strikes can remain up to 30 The threat of lightning strikes can remain up to 30

minutes after last clap of thunder is heardminutes after last clap of thunder is heard

Electricity forces in the patient have dissipated by Electricity forces in the patient have dissipated by �� Electricity forces in the patient have dissipated by Electricity forces in the patient have dissipated by

the time rescuers reach the victimthe time rescuers reach the victim

�� Arrested patients have a good chance of survival if Arrested patients have a good chance of survival if

rapid ALS is appliedrapid ALS is applied

�� Immediate CPR startedImmediate CPR started

�� Defibrillation for ventricular fibrillationDefibrillation for ventricular fibrillation

�� Airway controlAirway control

Lightning Strikes

�� Strike usually causes asystoleStrike usually causes asystole

��Property of automaticity usually restarts a Property of automaticity usually restarts a rhythmrhythm

��VF develops secondarily to the initial VF develops secondarily to the initial respiratory arrest if not corrected fast respiratory arrest if not corrected fast respiratory arrest if not corrected fast respiratory arrest if not corrected fast enoughenough

�� If not arrested at the initial strike, If not arrested at the initial strike, unlikely to arrest later unlikely to arrest later

�� Put attention to the arrested patients firstPut attention to the arrested patients first

�� External wounds, if any, treated as thermal External wounds, if any, treated as thermal burnsburns

Pathway of Travel Through the

Body of a Lightning Strike

�� Least resistanceLeast resistance

�� Nerves (designed to carry electrical signals)Nerves (designed to carry electrical signals)

�� Blood vessels (filled with water & electrolytes)Blood vessels (filled with water & electrolytes)

MuscleMuscle�� MuscleMuscle

�� Mucous membranes (moist)Mucous membranes (moist)

�� Intermediate resistanceIntermediate resistance

�� SkinSkin

�� Most resistanceMost resistance

�� Tendons, fat, boneTendons, fat, bone

Inhalation Injury

�� Mechanism of Mechanism of

injuryinjury

�� Carbon monoxide Carbon monoxide

�� Thermal injury Thermal injury �� Thermal injury Thermal injury

(injury above the (injury above the

glottis)glottis)

�� Chemical injury Chemical injury

(injury below the (injury below the

glottis)glottis)

Grade 4 Inhalation burn of trachea to R and L bronchi.

*Note – Inhalation burns are rated 1 thru 4 (4 is worst)

Abuse/Neglect�� Delay in careDelay in care

�� Inconsistent storyInconsistent story

�� Distribution does Distribution does

not fit storynot fit storynot fit storynot fit story

�� Other signs of Other signs of

abuseabuse

�� All pediatric burns All pediatric burns

require require

psychosocial psychosocial

evaluationevaluation

Full thickness dunk in hot water bathtub

*Note – NOT burned behind knees or above waist

Behind knees not burned because child pulled his legs up.

Uninjured

skin - pt

African

American

If child had stepped into tub, bottoms of feet could

not have been burned this severely. Child was

held/dunked by an adult. (same pt.)

Foley placed quickly due to swelling. (same pt.)

Initial Assessment

��Stop the burning Stop the burning process as process as assessment is assessment is startedstartedstartedstarted

��Airway/cAirway/c--spine spine immobilizationimmobilization

��BreathingBreathing

��CirculationCirculation

Don’t forget ABC’s !!!

�� Intubation can be difficult due to tissue Intubation can be difficult due to tissue

swelling which worsens with time.swelling which worsens with time.

Major swelling to face after burn

* Note - ETT placement is measured by gums or teeth, NOT lip line

*Note – ETT tied and not taped, tape will not stick to

burn area and can cause more injury to tissue

Initial Evaluation - Being Suspicious

of Abuse/Neglect

�� Events leading to Events leading to

injuryinjury

�� Medical historyMedical history

�� Does distribution fit Does distribution fit

injury injury

��Does it look how Does it look how

they say it they say it

happened?happened?

Second Step of Assessment

Focused History & Physical Exam

�� Determine extentDetermine extent

�� Rule of NinesRule of Nines

�� Minimize edemaMinimize edemaMinimize edemaMinimize edema

�� CoolingCooling

�� Elevation of extremityElevation of extremity

�� Fluid resuscitationFluid resuscitation

�� 20 ml/kg adult and 20 ml/kg adult and

pediatric patients if pediatric patients if

fluids are neededfluids are needed

Remove patient from burn source

Routine Trauma Care

Assess particularly for airway and / or circulatory

compromise

⇓

Evaluate depth of burn and estimate extent using Rule of

Nines.

Region X SOP BURNS, ADULT

Nines.

⇓

MORPHINE SULFATE 2 mg IVP slowly over 2 minutes

May repeat every 2 minutes as needed

to a maximum total of 10 mg

⇓

FURTHER CARE DEPENDENT ON MECHANISM OF

BURN:

⇓ ⇓SOP

Page 36

⇓

ELECTRICAL BURNS - Adult

Ensure rescuer safetyRemove from source• Immobilize• Assess for dysrhythmia• Identify and document any entrance and • Identify and document any entrance and

exit wounds• Assess neurovascular status of affected

part• Cover wounds with dry sterile dressings

� SOP Page 36

⇓

CHEMICAL BURNS - Adult

• Refer to Haz / Mat protocol• If powdered chemical, brush away excess• Remove clothing if possible• Flush burn area with sterile water or saline • •IF EYE INVOLVEMENT• •IF EYE INVOLVEMENT• Rapid visual acuity• Remove contact lens and irrigate with saline or

sterile water continuously. DO NOT CONTAMINATE THE UNINJURED EYE WITH EYE IRRIGATION

• SOP Page 36

⇓

INHALATION BURNS - Adult

Note presence of wheezing, hoarseness,

stridor, carbonaceous sputum, singed nasal

hair.hair.

May include CO poisoning, heat or smoke

inhalation

High flow oxygen

Consider advanced airway

SOP Page 36

⇓

THERMAL BURNS - Adult

•Superficial (1st degree)Cool burned area with water or saline<20% body surface involved, apply sterile saline soaked

dressings.DO NOT OVER COOL major burns or apply ice directly to

burned areas.

•Partial or Full thickness (2nd or 3rd degree)Wear sterile gloves / mask while burn areas exposedCover burn wound with DRY sterile dressingsPlace patient on clean sheet on stretcher, cover patient with

dry clean sheets and blanket.

� NOTE: Use of ice for cooling is absolutely contraindicated.

SOP Page 36

Region X SOP for Pediatric Burns

�� Follow the same format for the adult patient Follow the same format for the adult patient

with burnswith burns

�� Protect all patients from overProtect all patients from over--exposure to exposure to �� Protect all patients from overProtect all patients from over--exposure to exposure to

coolingcooling

��Need to prevent hypothermiaNeed to prevent hypothermia

�� Assess for potential of child abuse Assess for potential of child abuse

�� Contact Medical Control for pain controlContact Medical Control for pain control

Monitor Fluid Resuscitation

�� Patients may require more Patients may require more

fluid with prefluid with pre--existing existing

dehydration, inhalation dehydration, inhalation

injury, & full thickness injury, & full thickness

burnsburns

Parkland formula used as Parkland formula used as �� Parkland formula used as Parkland formula used as

a a guideline in the a a guideline in the

hospitalhospital

�� Foley catheter inserted to Foley catheter inserted to

measure outputmeasure output

�� Goal for urine output isGoal for urine output is

3030--50cc/hour50cc/hour

Parkland Formula

�� Parkland formula is used as a guide to Parkland formula is used as a guide to

determine proper fluid resuscitationdetermine proper fluid resuscitation

�� 4 ml of LR /kg/% of TBSA = total fluid 4 ml of LR /kg/% of TBSA = total fluid �� 4 ml of LR /kg/% of TBSA = total fluid 4 ml of LR /kg/% of TBSA = total fluid

requirement in first 24hrs. requirement in first 24hrs.

��½ over first 8hrs. ½ over first 8hrs.

��Other ½ over the next 16 hoursOther ½ over the next 16 hours

�� VERY IMPORTANT to accurately record VERY IMPORTANT to accurately record

fluids given in the fieldfluids given in the field

Example:

A patient with 56% TBSA burned, weighing A patient with 56% TBSA burned, weighing

110kg110kg

[4] x [14] x [110][4] x [14] x [110]

Total fluid = 6160 mL in first 24 hoursTotal fluid = 6160 mL in first 24 hours

3080 mL given over 8 hours = 385mL/3080 mL given over 8 hours = 385mL/hrhr

3080 mL given over 16 hours = 193mL/3080 mL given over 16 hours = 193mL/hrhr

Importance of Fluid Resuscitation

�� Inadequate fluid resuscitation can lead to Inadequate fluid resuscitation can lead to

renal failure and deathrenal failure and death

��Lactated Ringer's solution (LR) Lactated Ringer's solution (LR) -- is a is a

solution that is solution that is isotonicisotonic with with bloodblood and and

intended for intended for intravenous administrationintravenous administration. .

��For more info…For more info…

��http://en.wikipedia.org/wiki/Lactated_Rinhttp://en.wikipedia.org/wiki/Lactated_Rin

ger%27s_solutionger%27s_solution

Poor urine output to good output

Massive protein and plasma loss all the way to near normal urine.

*Note - your normal urine should be clear with proper fluid intake

You can tell how bad pt condition is by what

systems are affected

Sample Transfer Criteria: Loyola

�� 10% or more TBSA 10% or more TBSA partial thickness burnpartial thickness burn

�� Any full thickness Any full thickness burnburn

Burns to feet, hands, Burns to feet, hands,

�� Chemical burnsChemical burns

�� Inhalation burnsInhalation burns

�� Burn injury with preBurn injury with pre--existing medical existing medical conditionsconditions�� Burns to feet, hands, Burns to feet, hands,

face & perineumface & perineum

�� Circumfrential burnsCircumfrential burns

�� Concurrent traumaConcurrent trauma

conditionsconditions

�� Burned children in Burned children in hospitals without hospitals without qualified personnel or qualified personnel or equipment qualified to equipment qualified to care for childrencare for children

�� Burns requiring extensive Burns requiring extensive rehabilitationrehabilitation

Transfer Mode

�� Determined by Determined by

transferring MD and transferring MD and

accepting MDaccepting MD

�� Patients may be Patients may be �� Patients may be Patients may be

accepted directly from accepted directly from

the scene or by a the scene or by a

transferring hospitaltransferring hospital

Remember why we’re here…

More Info

�� The following photos are of some advanced The following photos are of some advanced

care equipment and techniquescare equipment and techniques

�� Many of the photos are quite graphicMany of the photos are quite graphic�� Many of the photos are quite graphicMany of the photos are quite graphic

�� Burns often evolve over timeBurns often evolve over time

��What is initially seen in the field evolves What is initially seen in the field evolves

in the ED and over the early first days in the ED and over the early first days

after the initial insultafter the initial insult

Doppler being used to find a pedal pulse

Flash burn to face – eye drops being

instilled

Escharotomy

�� Surgical approach Surgical approach

to prevent/treat to prevent/treat

compartment compartment

syndromesyndromesyndromesyndrome

�� Incision extends Incision extends

through entire through entire

depth of skindepth of skin

Full thickness with chest and abdominal

escharotomy

Escharotomy of right leg

Bilateral escharotomy

Infant arm escharotomy

Debridement & Grafting

�� Surgical removal of dead/infected tissue.Surgical removal of dead/infected tissue.

�� May have grafting procedure after May have grafting procedure after

debridementdebridement

Initial Wound Care of Burns

�� Keep patient warmKeep patient warm

�� Initial cooling Initial cooling

methods may cool methods may cool

patient too muchpatient too muchpatient too muchpatient too much

�� NoNo wet dressings or wet dressings or

ice for partial ice for partial

thickness or full thickness or full

thickness burnsthickness burns

�� ED may consult with a ED may consult with a

burn centerburn center

Principles of Dressing Application

�� When dressings are applied, skin should not be When dressings are applied, skin should not be touching skintouching skin

�� Place gauze between fingers or toes before Place gauze between fingers or toes before wrapping the extremity.wrapping the extremity.

�� Begin wrapping distally and work upwardsBegin wrapping distally and work upwards�� Begin wrapping distally and work upwardsBegin wrapping distally and work upwards

�� Never pull tight on the dressingsNever pull tight on the dressings

�� Anticipate injuries to swellAnticipate injuries to swell

�� If saline dressings are used, wring out the dressing If saline dressings are used, wring out the dressing so it is not drippingso it is not dripping

�� Use the wetUse the wet--toto--dry techniquedry technique

�� Place dry dressings over the moist dressing Place dry dressings over the moist dressing

Dressings�� No creams are appliedNo creams are applied

�� Sterile saline would be solution of choice if one is Sterile saline would be solution of choice if one is neededneeded

�� Saline is isotonicSaline is isotonic

�� Accepted cleansing agent used in the hospitalAccepted cleansing agent used in the hospital

�� Review proper burn / wound injury careReview proper burn / wound injury care�� Review proper burn / wound injury careReview proper burn / wound injury care

�� Types and sizes of dressingsTypes and sizes of dressings

�� Temperature regulation Temperature regulation

�� Dry dressings for 2Dry dressings for 2ndnd and 3and 3rdrd degree burnsdegree burns

�� Keep patient warm Keep patient warm

•• Avoid hypothermiaAvoid hypothermia

–– Burned skin loses ability to retain heatBurned skin loses ability to retain heat

Scenarios

�� The following scenarios will require finding The following scenarios will require finding

out the burn severity and percentage of burn out the burn severity and percentage of burn

for each pt.for each pt.for each pt.for each pt.

��Use the Rule of Nine’sUse the Rule of Nine’s

��Percent of burn estimation should be Percent of burn estimation should be

within +/within +/-- 4%4%

Scenario #1

�� Called for a 10 year old girl that spilled hot Called for a 10 year old girl that spilled hot

chocolate on chest and lap. Upon arrival pt chocolate on chest and lap. Upon arrival pt

complains of severe pain and this is what is complains of severe pain and this is what is complains of severe pain and this is what is complains of severe pain and this is what is

visually noted… visually noted…

Same pt, side view

Scenario #1�� What classification of burn(s) is it?What classification of burn(s) is it?

� Full thickness (3rd) with partial (2nd) on edges

�� What is the percent of burn area?What is the percent of burn area?�� Approx. 14 Approx. 14 -- 16%16%

�� How do you call it in?How do you call it in?�� How do you call it in?How do you call it in?�� Be descriptive as to how the burn happened and Be descriptive as to how the burn happened and

how it appearshow it appears

�� What is your care?What is your care?

��Remember to remove diapers from Remember to remove diapers from infants as they can retain the hot fluids infants as they can retain the hot fluids and continue the burning processand continue the burning process

Scenario #2

�� Called for a 19 year old that was burned by Called for a 19 year old that was burned by

a backyard firepit. Upon arrival pt a backyard firepit. Upon arrival pt

complains of pain/tightness in left hand and complains of pain/tightness in left hand and complains of pain/tightness in left hand and complains of pain/tightness in left hand and

leg. leg.

Scenario #2

�� What classification of burn(s) is it?What classification of burn(s) is it?

� 2nd and 3rd to leg

� 1st and 2nd to forearm, at least 1st to hand

�� What is the percent of burn area?What is the percent of burn area?�� What is the percent of burn area?What is the percent of burn area?

�� Approx. 13% Approx. 13%

�� How do you call it in?How do you call it in?

�� Note the areas of blistering and soot. Those Note the areas of blistering and soot. Those areas may be hard to determine degree and % areas may be hard to determine degree and % of burn.of burn.

�� What is your care?What is your care?

Scenario #3

�� Call for a 4 year old that put water in a bath Call for a 4 year old that put water in a bath

tub that was too hot. Mother states that he tub that was too hot. Mother states that he

was sitting in tub and running water by was sitting in tub and running water by was sitting in tub and running water by was sitting in tub and running water by

himself. Pt says his legs “kind of hurt”.himself. Pt says his legs “kind of hurt”.

Uninjured

Skin

Scenario #3

�� What classification of burn(s) is it?What classification of burn(s) is it?

�� 33rdrd degreedegree

�� What is the percent of burn area?What is the percent of burn area?

�� Approx. 42% (buttocks, both legs and Approx. 42% (buttocks, both legs and perineum)perineum)perineum)perineum)

�� How do you call it in?How do you call it in?

�� Note degree, amount, cause and the fact that it Note degree, amount, cause and the fact that it is circumferential. Also, pass on suspicions of is circumferential. Also, pass on suspicions of abuse based on story.abuse based on story.

�� What is your care?What is your care?

Questions on burns ?

Intraosseous Needle Insertion

�� IndicationsIndications

��Shock, arrest, impending arrestShock, arrest, impending arrest

��Unconscious/unresponsive to verbal Unconscious/unresponsive to verbal stimulistimulistimulistimuli

��2 unsuccessful IV attempts or 90 second 2 unsuccessful IV attempts or 90 second durationduration

��Adult needle = weight over 40 kg (88#)Adult needle = weight over 40 kg (88#)

��Pediatric needle = weight 3 Pediatric needle = weight 3 –– 39 kg (88#)39 kg (88#)

IO Contraindications

�� Fracture of the tibia or femurFracture of the tibia or femur

�� Infection at the insertion siteInfection at the insertion site

�� Previous orthopedic procedure (knee Previous orthopedic procedure (knee replacement; previous IO insertion within replacement; previous IO insertion within 48 hours)48 hours)replacement; previous IO insertion within replacement; previous IO insertion within 48 hours)48 hours)

�� PrePre--existing medical conditionexisting medical condition

�� Inability to locate landmarks Inability to locate landmarks

�� Excessive tissue at the siteExcessive tissue at the site

��Obese leg Obese leg –– hold leg up by the foot and hold leg up by the foot and allow tissue to fall away if possibleallow tissue to fall away if possible

IO Equipment

�� Driver with needle Driver with needle attachedattached

�� Needle length Needle length for amount of for amount of tissue to tissue to penetratepenetrate

IO Insertion Steps

�� BSI precautionsBSI precautions

�� Prepare equipmentPrepare equipment

�� IV bag and tubing, start pak, IO needle, IV bag and tubing, start pak, IO needle, IO drill, EZIO drill, EZ--connect tubing, syringe with connect tubing, syringe with normal saline, arm bandnormal saline, arm bandnormal saline, arm bandnormal saline, arm band

�� Prepare site Prepare site

�� Insert needle at 90Insert needle at 9000 angleangle

�� Remove driver from needle setRemove driver from needle set

�� Remove stylet (rotate counterclockwise)Remove stylet (rotate counterclockwise)

�� Connect primed EZConnect primed EZ--connect tubingconnect tubing

�� Use the syringe to aspirate then flush with Use the syringe to aspirate then flush with

NSNS

�� Remove syringe from EZ connect tubing Remove syringe from EZ connect tubing

and attach IV tubingand attach IV tubing

�� Apply pressure to the IV bagApply pressure to the IV bag�� Apply pressure to the IV bagApply pressure to the IV bag

�� Secure IO needle and tubingSecure IO needle and tubing

�� Apply wristband to same side wristApply wristband to same side wrist

�� If IO insertion missed, still apply If IO insertion missed, still apply

wristband to indicate a missed attemptwristband to indicate a missed attempt

Confirmation of IO Insertion

�� Needle stands up on ownNeedle stands up on own

�� Ability to aspirate bone marrowAbility to aspirate bone marrow

�� Easy flushing without resistanceEasy flushing without resistance�� Easy flushing without resistanceEasy flushing without resistance

�� Good IV flowGood IV flow

��Remember to use pressure bag around IV Remember to use pressure bag around IV

tubingtubing

Additional Information

�� Poison Control CenterPoison Control Center

��11--800800--222222--12221222

�� IAFF Burn Foundation IAFF Burn Foundation

��Educational materialsEducational materials

��http://burn.iaff.orghttp://burn.iaff.org

Bibliography�� Original PowerPoints from…Original PowerPoints from…

�� Burns CE Region 8 Sept. 2007Burns CE Region 8 Sept. 2007

�� Laurie Herbert RN, BSNLaurie Herbert RN, BSN

�� Burn InjuryBurn Injury

�� Kathy G. Supple RN, ACNP, CCRNKathy G. Supple RN, ACNP, CCRN

�� Loyola Burn Nurse Practitioner Loyola Burn Nurse Practitioner

Bledsoe, B., Porter, R., Cherry, R. Essentials of Paramedic Bledsoe, B., Porter, R., Cherry, R. Essentials of Paramedic �� Bledsoe, B., Porter, R., Cherry, R. Essentials of Paramedic Bledsoe, B., Porter, R., Cherry, R. Essentials of Paramedic Care. 3Care. 3rdrd Edition. Brady. 2009.Edition. Brady. 2009.

�� Campbell, J. Basic Trauma Life Support, 5th Edition, Campbell, J. Basic Trauma Life Support, 5th Edition, Brady. 2004Brady. 2004

�� International Association of Fire Fighters Burn International Association of Fire Fighters Burn Foundation. First Responder Guide to Burn Injury Foundation. First Responder Guide to Burn Injury Assessment and Treatment. 2007.Assessment and Treatment. 2007.

�� Region X Standard Operating Procedures, March 2007 Region X Standard Operating Procedures, March 2007 Amended version May 1, 2008Amended version May 1, 2008

�� www.lightningsafety.noaa.gov/outdoors.htmwww.lightningsafety.noaa.gov/outdoors.htm