burn injuries by donald hudson, d.o., facep/acoep

Burn InjuriesBurn Injuries

ByBy

Donald Hudson, D.O., FACEP/ACOEPDonald Hudson, D.O., FACEP/ACOEP

EpidemiologyEpidemiology Tissue injury caused by thermal, Tissue injury caused by thermal,

electrical, or chemical agentselectrical, or chemical agents Can be fatal, disfiguring, or Can be fatal, disfiguring, or

incapacitatingincapacitating ~ 1.25 million burn injuries per year~ 1.25 million burn injuries per year

• 45,000 hospitalized per year45,000 hospitalized per year• 4500 die per year (3750 from housefires)4500 die per year (3750 from housefires)

3rd largest cause of accidental death 3rd largest cause of accidental death

Risk FactorsRisk Factors

Fire/CombustionFire/Combustion• FirefighterFirefighter• Industrial WorkerIndustrial Worker• Occupant of burning structuresOccupant of burning structures

Chemical ExposureChemical Exposure• Industrial WorkerIndustrial Worker

Electrical ExposureElectrical Exposure• ElectricianElectrician• Electrical Power Distribution WorkerElectrical Power Distribution Worker

Anatomy and Physiology Anatomy and Physiology of Skinof Skin

SkinSkin

Largest body organ. Much more Largest body organ. Much more than a passive organ.than a passive organ.• Protects underlying tissues from injuryProtects underlying tissues from injury• Temperature regulationTemperature regulation• Acts as water tight seal, keeping body Acts as water tight seal, keeping body

fluids influids in• Sensory organSensory organ

SkinSkin

Injuries to skin which result in loss, Injuries to skin which result in loss, have problems with:have problems with:• InfectionInfection• Inability to maintain normal water Inability to maintain normal water

balancebalance• Inability to maintain body temperatureInability to maintain body temperature

SkinSkin

Two layersTwo layers• EpidermisEpidermis• DermisDermis

EpidermisEpidermis• Outer cells are Outer cells are

deaddead• Act as protection Act as protection

and form water and form water tight sealtight seal

SkinSkin

EpidermisEpidermis• Deeper layers divide to produce the Deeper layers divide to produce the

stratum corneum and also contain stratum corneum and also contain pigment to protect against UV pigment to protect against UV radiationradiation

DermisDermis• Consists of tough, elastic connective Consists of tough, elastic connective

tissue which contains specialized tissue which contains specialized structuresstructures

Skin Skin

Dermis - Specialized StructuresDermis - Specialized Structures• Nerve endingsNerve endings• Blood vesselsBlood vessels• Sweat glandsSweat glands• Oil glands - keep skin waterproof, Oil glands - keep skin waterproof,

usually discharges around hair shaftsusually discharges around hair shafts• Hair follicles - produce hair from hair Hair follicles - produce hair from hair

root or papillaroot or papilla– Each follicle has a small muscle (arrectus pillorum) which can Each follicle has a small muscle (arrectus pillorum) which can

pull the hair upright and cause goose fleshpull the hair upright and cause goose flesh


Potential complicationsPotential complications• Fluid and Electrolyte loss Fluid and Electrolyte loss

HypovolemiaHypovolemia• Hypothermia, Infection, AcidosisHypothermia, Infection, Acidosis catecholamine release, catecholamine release,

vasoconstrictionvasoconstriction• Renal or hepatic failureRenal or hepatic failure• Formation of escharFormation of eschar• Complications of circumferential burnComplications of circumferential burn


An important step in management An important step in management is to determine depth and extent of is to determine depth and extent of damage to determine where and damage to determine where and how the patient should be treatedhow the patient should be treated

Types of Burn InjuriesTypes of Burn Injuries Thermal burnThermal burn

• Skin injurySkin injury• Inhalation injuryInhalation injury

Chemical burnChemical burn• Skin injurySkin injury• Inhalation injuryInhalation injury• Mucous membrane injuryMucous membrane injury

Electrical burnElectrical burn• LightningLightning

Radiation burnRadiation burn

Depth ClassificationDepth Classification

SuperficialSuperficial Partial thicknessPartial thickness Full thicknessFull thickness

Burn ClassificationsBurn Classifications

1st degree (Superficial burn)1st degree (Superficial burn)• Involves the epidermisInvolves the epidermis• Characterized by reddeningCharacterized by reddening• Tenderness and PainTenderness and Pain• Increased warmthIncreased warmth• Edema may occur, but no blisteringEdema may occur, but no blistering• Burn blanches under pressureBurn blanches under pressure• Example - sunburnExample - sunburn• Usually heal in ~ 7 daysUsually heal in ~ 7 days


First Degree BurnFirst Degree Burn(Superficial Burn)(Superficial Burn)


2nd degree2nd degree• Damage extends through the epidermis Damage extends through the epidermis

and involves the dermis.and involves the dermis.• Not enough to interfere with Not enough to interfere with

regeneration of the epitheliumregeneration of the epithelium• Moist, shiny appearanceMoist, shiny appearance• Salmon pink to red colorSalmon pink to red color• PainfulPainful• Does not have to blister to be 2nd degreeDoes not have to blister to be 2nd degree• Usually heal in ~7-21 daysUsually heal in ~7-21 days


2nd Degree 2nd Degree BurnBurn(Partial (Partial Thickness Thickness Burn)Burn)


3rd degree3rd degree• Both epidermis and dermis are destroyed Both epidermis and dermis are destroyed

with burning into SQ fatwith burning into SQ fat• Thick, dry appearanceThick, dry appearance• Pearly gray or charred black colorPearly gray or charred black color• Painless - nerve endings are destroyedPainless - nerve endings are destroyed• Pain is due to intermixing of 2nd degreePain is due to intermixing of 2nd degree• May be minor bleedingMay be minor bleeding• Cannot heal and require graftingCannot heal and require grafting


3rd Degree Burn3rd Degree Burn(Full Thickness (Full Thickness burn)burn)


Often it is not possible to predict Often it is not possible to predict the exact depth of a burn in the the exact depth of a burn in the acute phase. Some 2nd degree acute phase. Some 2nd degree burns will convert to 3rd when burns will convert to 3rd when infection sets in. When in doubt infection sets in. When in doubt call it 3rd degree.call it 3rd degree.

Body Surface Area Body Surface Area EstimationEstimation

Rule of Rule of NinesNines• AdultAdult

Palm Palm RuleRule

Body Surface Area Body Surface Area EstimationEstimation

Rule of Rule of NinesNines• PedsPeds

– For each yr For each yr over 1 yoa, over 1 yoa, subtract 1% subtract 1% from head and from head and add equally to add equally to legslegs

Palm RulePalm Rule

Burn Patient SeverityBurn Patient Severity

Factors to ConsiderFactors to Consider• Depth or ClassificationDepth or Classification• Body Surface area burnedBody Surface area burned• Age: Adult vs PediatricAge: Adult vs Pediatric• Preexisting medical conditionsPreexisting medical conditions• Associated TraumaAssociated Trauma

– blast injury blast injury

– fall injuryfall injury

– airway compromiseairway compromise

– child abusechild abuse

Burn Patient SeverityBurn Patient Severity

Patient agePatient age• Less than 2 or greater than 55Less than 2 or greater than 55• Have increased incidence of complicationHave increased incidence of complication

Burn configurationBurn configuration• Circumferential burns can cause total Circumferential burns can cause total

occlusion of circulation to an area due to occlusion of circulation to an area due to edemaedema

• Restrict ventilation if encircle the chestRestrict ventilation if encircle the chest• Burns on joint area can cause disability due to Burns on joint area can cause disability due to

scar formationscar formation

Critical Burn CriteriaCritical Burn Criteria

330 0 > 10% BSA> 10% BSA 2200 > 30% BSA > 30% BSA

• >20% pediatric>20% pediatric Burns with respiratory injuryBurns with respiratory injury Hands, face, feet, or genitaliaHands, face, feet, or genitalia Burns complicated by other traumaBurns complicated by other trauma Underlying health problemsUnderlying health problems Electrical and deep chemical burns Electrical and deep chemical burns

Moderate Burn CriteriaModerate Burn Criteria

3300 2-10% BSA 2-10% BSA 2200 15-30% BSA 15-30% BSA

• 10-20% pediatric10-20% pediatric Excluding hands, face, feet, or Excluding hands, face, feet, or

genitaliagenitalia Without complicating factorsWithout complicating factors

Minor Burn CriteriaMinor Burn Criteria

3300 < 2% BSA < 2% BSA 2200 < 15% BSA < 15% BSA

• <10% pediatric<10% pediatric 1100 < 20% BSA < 20% BSA

Thermal Burn Injury Thermal Burn Injury PathophysiologyPathophysiology

Emergent phaseEmergent phase• Response to pain Response to pain catecholamine release catecholamine release

Fluid shift phaseFluid shift phase• massive shift of fluid - intravascular massive shift of fluid - intravascular

extravascularextravascular Hypermetabolic phaseHypermetabolic phase

demand for nutrients demand for nutrients repair tissue repair tissue damagedamage

Resolution phaseResolution phase• scar tissue and remodeling of tissuescar tissue and remodeling of tissue


Jackson’s Thermal Wound TheoryJackson’s Thermal Wound Theory• Zone of CoagulationZone of Coagulation

– area nearest burn area nearest burn

– cell membranes rupture, clotted blood and thrombosed vesselscell membranes rupture, clotted blood and thrombosed vessels

• Zone of StasisZone of Stasis– area surrounding zone of coagulation area 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


Eschar formationEschar formation• Skin denaturingSkin denaturing

– hard and leatheryhard and leathery

• Skin constricts over woundSkin constricts over wound– increased pressure underneathincreased pressure underneath

– restricts blood flowrestricts blood flow

• Respiratory compromiseRespiratory compromise– secondary to circumferential eschar around the thoraxsecondary to circumferential eschar around the thorax

• Circulatory compromiseCirculatory compromise– secondary to circumferential eschar around extremitysecondary to circumferential eschar around extremity

Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury Remove to safe area, if possibleRemove to safe area, if possible Stop the burning processStop the burning process

• Extinguish fire - cool smoldering areasExtinguish fire - cool smoldering areas• Remove clothing and jewelryRemove clothing and jewelry• Cut around areas where clothing is Cut around areas where clothing is

stuck to skinstuck to skin• Cool adherent substances (Tar, Plastic)Cool adherent substances (Tar, Plastic)

Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury

Pertinent HistoryPertinent History• How long ago?How long ago?• What care has been given?What care has been given?• What burned with?What burned with?• Burned in closed space?Burned in closed space?

– Products of combustion present?Products of combustion present?

– How long exposed?How long exposed?

– Loss of consciousness?Loss of consciousness?

• Past medical history?Past medical history?

Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury Airway and BreathingAirway and Breathing

• Assess for potential airway involvementAssess for potential airway involvement– soot or singing involving mouth, nose, hair, face, facial hairsoot or singing involving mouth, nose, hair, face, facial hair– coughing, black sputumcoughing, black sputum– enclosed fire environmentenclosed fire environment

• Assist ventilations as neededAssist ventilations as needed• 100% oxygen via NRB if:100% oxygen via NRB if:

– Moderate or critical burnModerate or critical burn– Patient unconsciousPatient unconscious– Signs of possible airway burn/inhalation injurySigns of possible airway burn/inhalation injury– History of exposure to carbon monoxide or smokeHistory of exposure to carbon monoxide or smoke

Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury Airway and Breathing (cont)Airway and Breathing (cont)

• Respiratory rates are unreliable due to Respiratory rates are unreliable due to toxic combustion product’stoxic combustion product’s

– May cause depressant effectsMay cause depressant effects

• Be prepared to intubate early if patient Be prepared to intubate early if patient has inhalation injurieshas inhalation injuries

– Prep early for RSIPrep early for RSI

Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury Circulatory StatusCirculatory Status

• Burns do not cause rapid onset of Burns do not cause rapid onset of hypovolemic shockhypovolemic shock

• If shock is present, look for other If shock is present, look for other injuriesinjuries

• Circumferential burns may cause Circumferential burns may cause decreased perfusion to extremitydecreased perfusion to extremity


OtherOther• Assess Burn Surface Area & Associated Assess Burn Surface Area & Associated

InjuriesInjuries• AnalgesiaAnalgesia• Avoid topical agents except as directed Avoid topical agents except as directed

by local burn centersby local burn centers– e.g. silvadenee.g. silvadene

• Fluid TherapyFluid Therapy


Consider Fluid Therapy forConsider Fluid Therapy for• >10% BSA 3>10% BSA 300

• >15% BSA 2>15% BSA 200

• >30-50% BSA 1>30-50% BSA 100 with accompanying 2 with accompanying 20 0

LR using Parkland Burn FormulaLR using Parkland Burn Formula• 4 (2-4) cc/kg/% burn4 (2-4) cc/kg/% burn• 1/2 in first 8 hours1/2 in first 8 hours• 1/2 over 2nd 16 hours1/2 over 2nd 16 hours


Fluid therapyFluid therapy• ObjectiveObjective

– HR < 110/minuteHR < 110/minute

– Normal sensorium (awake, alert, oriented)Normal sensorium (awake, alert, oriented)

– Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi)Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi)

– Resuscitation formula’s provide estimates, adjust to individual Resuscitation formula’s provide estimates, adjust to individual patient responsespatient responses

• Start through burn if necessary, upper Start through burn if necessary, upper extremities preferredextremities preferred

• Monitor for Pulmonary EdemaMonitor for Pulmonary Edema


AnalgesiaAnalgesia• Morphine SulfateMorphine Sulfate

– 2-3 mg repeated q 10 minutes titrated to adequate ventilations 2-3 mg repeated q 10 minutes titrated to adequate ventilations and blood pressureand blood pressure

– 0.1 mg/kg for pediatric0.1 mg/kg for pediatric

– May require large but tolerable total dosesMay require large but tolerable total doses


Treat Burn Wound Treat Burn Wound • Low priority - After ABC’s and initiation Low priority - After ABC’s and initiation

of IV’sof IV’s• Do not rupture blistersDo not rupture blisters• Cover with sterile dressingsCover with sterile dressings

– Moist: Controversial, limit to small areas (<10%) or limit time of Moist: Controversial, limit to small areas (<10%) or limit time of applicationapplication

– Dry: Use for larger areas due to concern for hypothermiaDry: Use for larger areas due to concern for hypothermia

– Cover with burn sheetCover with burn sheet

• No “Goo” on burn unless directed by No “Goo” on burn unless directed by burn centerburn center


Transport ConsiderationsTransport Considerations• Appropriate FacilityAppropriate Facility

– Burn Center or NotBurn Center or Not

• Factor to considerFactor to consider– Burn Patient Severity CriteriaBurn Patient Severity Criteria

– Critical, Moderate, Minor Burn CriteriaCritical, Moderate, Minor Burn Criteria

– Confounding factorsConfounding factors

– Transport resourcesTransport resources

Inhalation InjuryInhalation Injury

Anticipate respiratory problems:Anticipate respiratory problems:• Head, Face, Neck or ChestHead, Face, Neck or Chest• Nasal or eyebrow hairs are singedNasal or eyebrow hairs are singed• Hoarseness, tachypnea, drooling presentHoarseness, tachypnea, drooling present• Loss of consciousness in burned areaLoss of consciousness in burned area• Nasal/Oral mucosa red or dryNasal/Oral mucosa red or dry• Soot in mouth or noseSoot in mouth or nose• Coughing up black sputumCoughing up black sputum• In enclosed burning area (e.g. small In enclosed burning area (e.g. small

apartment)apartment)

Inhalation InjuryInhalation Injury

Burned or exposed to products of Burned or exposed to products of combustion in closed spacecombustion in closed space

Cough present, especially if Cough present, especially if productive of carbonaceous sputumproductive of carbonaceous sputum

Any patient in fire has potential of Any patient in fire has potential of hypoxia and Carbon monoxide hypoxia and Carbon monoxide poisoningpoisoning

Inhalation Injury Inhalation Injury

Supraglottic InjurySupraglottic Injury• Susceptible to injury from high Susceptible to injury from high

temperaturestemperatures• May result in immediate edema of May result in immediate edema of

pharynx and larynxpharynx and larynx– Brassy coughBrassy cough

– StridorStridor

– HoarsenessHoarseness

– Carbonaceous sputumCarbonaceous sputum

– Facial burnsFacial burns

Inhalation Injury Inhalation Injury

Subglottic InjurySubglottic Injury• Rare injuryRare injury• Injury to Lung parenchymaInjury to Lung parenchyma• Usually due to superheated steam, Usually due to superheated steam,

aspiration of scalding liquid, or aspiration of scalding liquid, or inhalation of toxic chemicalsinhalation of toxic chemicals

• May be immediate but usually delayedMay be immediate but usually delayed– Wheezing or CracklesWheezing or Crackles

– Productive coughProductive cough

– BronchospasmBronchospasm

Inhalation injuryInhalation injury

Other ConsiderationsOther Considerations• Toxic gas inhalationToxic gas inhalation• Smoke inhalationSmoke inhalation• Carbon Monoxide poisoningCarbon Monoxide poisoning• Thiocyanate poisoningThiocyanate poisoning• Thermal burnsThermal burns• Chemical burnsChemical burns

Inhalation Injury Inhalation Injury ManagementManagement

Airway, Oxygenation and VentilationAirway, Oxygenation and Ventilation• Assess for airway edema early and oftenAssess for airway edema early and often• Consider early intubation, RSIConsider early intubation, RSI• When in doubt oxygenate and ventilateWhen in doubt oxygenate and ventilate• High flow oxygenHigh flow oxygen• Bronchodilators may be considered if Bronchodilators may be considered if

bronchospasm presentbronchospasm present• Diuretics not appropriate for pulmonary Diuretics not appropriate for pulmonary

edemaedema


CirculationCirculation• Treat for Shock (rare)Treat for Shock (rare)• IV AccessIV Access

– LR/NS large bore, multiple IVsLR/NS large bore, multiple IVs

– Titrate fluids to maintain systolic BP and perfusionTitrate fluids to maintain systolic BP and perfusion

• Avoid MAST/PASGAvoid MAST/PASG


Other ConsiderationsOther Considerations• Assess for other Burns and InjuriesAssess for other Burns and Injuries• Treat burn soft tissue injuryTreat burn soft tissue injury• Treat associated inhalation injury/poisoningTreat associated inhalation injury/poisoning

– Cyanide poisoning antidote kitCyanide poisoning antidote kit– Positive pressure ventilationPositive pressure ventilation– Hyperbaric chamber (carbon monoxide poisoning)Hyperbaric chamber (carbon monoxide poisoning)

Transport considerationsTransport considerations• Burn CenterBurn Center• Hyperbaric chamberHyperbaric chamber

Chemical BurnsChemical Burns

Usually associated with industrial Usually associated with industrial exposureexposure

First Consideration: Should you be First Consideration: Should you be here?here?• Does the patient need decontamination Does the patient need decontamination

before treatment?before treatment? Burning will continue as long as the Burning will continue as long as the

chemical is on the skinchemical is on the skin


AcidsAcids• Immediate coagulation-type necrosis Immediate coagulation-type necrosis

creating an eschar though self-limiting creating an eschar though self-limiting injuryinjury

– coagulation of protein results in necrosis in which affected coagulation of protein results in necrosis in which affected cells or tissue are converted into a dry, dull, homogeneous cells or tissue are converted into a dry, dull, homogeneous eosinophilic mass without nucleieosinophilic mass without nuclei


Bases (Alkali)Bases (Alkali)• Liquefactive necrosis with continued Liquefactive necrosis with continued

penetration into deeper tissue penetration into deeper tissue resulting in extensive injuryresulting in extensive injury

– characterized by dull, opaque, partly or completely fluid characterized by dull, opaque, partly or completely fluid remains of tissueremains of tissue

Dry ChemicalsDry Chemicals• Exothermic reaction with waterExothermic reaction with water

Chemical Burn Chemical Burn ManagementManagement

Definitive treatment is to get the Definitive treatment is to get the chemical off!chemical off!

Begin washing immediately - Begin washing immediately - removal the patient’s clothing as removal the patient’s clothing as you washyou wash• Watch for the socks and shoes, they Watch for the socks and shoes, they

trap chemicalstrap chemicals


Liquid ChemicalsLiquid Chemicals• wash off with copious amounts of fluidwash off with copious amounts of fluid

Dry ChemicalsDry Chemicals• brush away as much of the chemicals brush away as much of the chemicals

as possibleas possible• then wash off with large quantities of then wash off with large quantities of

water water Flush for 20-30 minutes to remove Flush for 20-30 minutes to remove

all chemicalsall chemicals


Do not attempt neutralizationDo not attempt neutralization• can cause additional chemical or can cause additional chemical or

thermal burns from the heat of thermal burns from the heat of neutralizationneutralization

Assess and Deliver secondary care Assess and Deliver secondary care as with other thermal and as with other thermal and inhalation burnsinhalation burns

Chemical Burn to Eye Chemical Burn to Eye ManagementManagement Flood the eye with copious Flood the eye with copious

amounts of water amounts of water onlyonly• Never place chemical antidote in eyesNever place chemical antidote in eyes

Flush using LR/NS/HFlush using LR/NS/H22O from medial O from medial to lateral for at least 15 minutesto lateral for at least 15 minutes• Nasal CannulaNasal Cannula• IV Ad SetIV Ad Set

Remove contact lensesRemove contact lenses• May trap irritantsMay trap irritants

Specific Chemical Specific Chemical ConsiderationsConsiderations Dry limeDry lime

• Brush offBrush off• Dry lime is water activatedDry lime is water activated• Then flush with copious amounts of waterThen flush with copious amounts of water

PhenolPhenol• Not water solubleNot water soluble• If available, use alcohol before flushing If available, use alcohol before flushing

except in eyesexcept in eyes• If unavailable, use copious amounts of If unavailable, use copious amounts of

waterwater

Specific Chemical Specific Chemical ConsiderationsConsiderations

Sodium/Potassium metalsSodium/Potassium metals• Reacts violently on contact with HReacts violently on contact with H2200

• Requires large amounts of waterRequires large amounts of water Sulfuric AcidSulfuric Acid

• Generates heat on exposure to H2O (exothermic)Generates heat on exposure to H2O (exothermic)• Wash with soap to neutralize or use copious Wash with soap to neutralize or use copious

amounts Hamounts H22OO

Tar BurnsTar Burns• Use cold packsUse cold packs• Do not pull off, can be dissolved laterDo not pull off, can be dissolved later

Specific Chemical Specific Chemical ConsiderationsConsiderations Chemical MaceChemical Mace

• CN or CSCN or CS– First chemical agents used by police/militaryFirst chemical agents used by police/military

• Mucous membrane and respiratory tract Mucous membrane and respiratory tract irritantirritant

• Skin sensitizerSkin sensitizer• ManagementManagement

– Treat respiratory distressTreat respiratory distress

– Continued irrigation and shower decontaminationContinued irrigation and shower decontamination

– Protect yourself firstProtect yourself first

– Decontaminate everything afterwardDecontaminate everything afterward

Specific Chemical Specific Chemical ConsiderationsConsiderations

Chemical MaceChemical Mace• OCOC

– Commonly referred to as “pepper spray”Commonly referred to as “pepper spray”

• Not as toxic as CN or CSNot as toxic as CN or CS• Mucous membrane irritant and skin Mucous membrane irritant and skin

sensitizersensitizer• May cause respiratory irritationMay cause respiratory irritation• ManagementManagement

– Treat respiratory distressTreat respiratory distress– Continued irrigation and shower decontaminationContinued irrigation and shower decontamination– Protect yourself firstProtect yourself first– Decontaminate everything afterwardDecontaminate everything afterward

Electrical BurnsElectrical Burns

Usually follows accidental contact Usually follows accidental contact with exposed object conducting with exposed object conducting electricityelectricity• Electrically powered devicesElectrically powered devices• Electrical wiringElectrical wiring• Power transmission linesPower transmission lines

Can also result from LightningCan also result from Lightning Damage depends on intensity of Damage depends on intensity of

currentcurrent

Electrical BurnsElectrical Burns Current kills, voltage simply determines Current kills, voltage simply determines

whether current can enter the bodywhether current can enter the body• Ohm’s law: I=V/ROhm’s law: I=V/R

Electrical follows shortest path to Electrical follows shortest path to groundground

Low VoltageLow Voltage• usually cannot enter body unless:usually cannot enter body unless:

– Skin is broken or moistSkin is broken or moist

– Low Resistance (follows blood vessels/nerves)Low Resistance (follows blood vessels/nerves)

High VoltageHigh Voltage• easily overcomes resistanceeasily overcomes resistance


Severity depends upon:Severity depends upon:• what tissue current passes throughwhat tissue current passes through• width or extent of the current pathwaywidth or extent of the current pathway• AC or DCAC or DC• duration of current contactduration of current contact


Most damage done is due to heat Most damage done is due to heat produced as current flows through produced as current flows through tissuestissues

Skin burns where current enters Skin burns where current enters and leaves can be almost trivial and leaves can be almost trivial lookinglooking• Everything between can be cookedEverything between can be cooked

Higher voltage may result in more Higher voltage may result in more obvious external burnsobvious external burns


Alternating Current (AC)Alternating Current (AC)• Tetanic muscle contraction may occur Tetanic muscle contraction may occur

resulting in:resulting in:– Muscle injuryMuscle injury

– Tendon RuptureTendon Rupture

– Joint DislocationJoint Dislocation

– FracturesFractures

• Spasms may keep patient from freeing Spasms may keep patient from freeing oneself from currentoneself from current


Contact with Alternating Current Contact with Alternating Current can also result in:can also result in:• Cardiac arrhythmiasCardiac arrhythmias• Apnea Apnea • SeizuresSeizures


In addition to contact burns, In addition to contact burns, patients can also develop flash patients can also develop flash burns when the current arcs near burns when the current arcs near themthem• Flame burns may occur when clothing Flame burns may occur when clothing

ignites after exposure to electrical ignites after exposure to electrical currentcurrent


LightningLightning• HIGH VOLTAGE!!!HIGH VOLTAGE!!!• Injury may result fromInjury may result from

– Direct StrikeDirect Strike

– Side FlashSide Flash

• Severe injuries often resultSevere injuries often result• Provides additional risk to EMS Provides additional risk to EMS

providerprovider– Weather capable of producing lightning is still in the areaWeather capable of producing lightning is still in the area


Pathophysiology of InjuriesPathophysiology of Injuries• External BurnExternal Burn• Internal BurnInternal Burn• Musculoskeletal injuryMusculoskeletal injury• Cardiovascular injuryCardiovascular injury• Respiratory injuryRespiratory injury• Neurologic injuryNeurologic injury• Rhabdomyolysis and Renal injuryRhabdomyolysis and Renal injury

Electrical Burn Electrical Burn ManagementManagement

Make sure current is offMake sure current is off• Lightning hazardsLightning hazards• Do not go near patient until current is Do not go near patient until current is

offoff ABC’sABC’s

• Ventilate and perform CPR as neededVentilate and perform CPR as needed• OxygenOxygen• ECG monitoringECG monitoring

– Treat dysrhythmiasTreat dysrhythmias


Rhabdomyolysis ConsiderationsRhabdomyolysis Considerations• Fluid?Fluid?• Dopamine?Dopamine?

Assess for additional injuriesAssess for additional injuries Consider transport to trauma Consider transport to trauma

centercenter


Any patient with an electrical Any patient with an electrical burnburn regardless of how trivial it looks regardless of how trivial it looks needs to go to the hospital. There is needs to go to the hospital. There is no way to tell how bad the burn is no way to tell how bad the burn is on the inside by the way it looks on on the inside by the way it looks on the outside.the outside.

Radiation ExposureRadiation Exposure

Waves or particles of energy that are Waves or particles of energy that are emitted from radioactive sourcesemitted from radioactive sources• Alpha radiationAlpha radiation

– large, travel a short distance, minimal penetrating abilitylarge, travel a short distance, minimal penetrating ability– can harm internal organs if can harm internal organs if inhaledinhaled, , ingestedingested or absorbed or absorbed

• Beta radiationBeta radiation– small, more energy, more penetrating abilitysmall, more energy, more penetrating ability– usually enter thru damaged skin, ingestion or inhalationusually enter thru damaged skin, ingestion or inhalation

• Gamma radiation & X-raysGamma radiation & X-rays– most dangerous penetrating radiationmost dangerous penetrating radiation– may produce localized skin burns and extensive internal damagemay produce localized skin burns and extensive internal damage


Radiation exposure may result in:Radiation exposure may result in:• external injuryexternal injury• contamination contamination • incorporation injuryincorporation injury• combined injuriescombined injuries


Effect of Injury dependent upon:Effect of Injury dependent upon:• duration of exposureduration of exposure• distance from the sourcedistance from the source• shieldingshielding

At risk for delayed complicationsAt risk for delayed complications

Radiation Exposure Radiation Exposure ManagementManagement

SAFETY!!!SAFETY!!!• Two Most Useful Tools for Radiation Two Most Useful Tools for Radiation

Incident ManagementIncident Management• Protective EquipmentProtective Equipment

Need for decontaminationNeed for decontamination Likelihood of survivalLikelihood of survival ABCs and Supportive CareABCs and Supportive Care

Pediatric BurnsPediatric Burns

Thin skinThin skin• increases severity of burning relative to adultsincreases severity of burning relative to adults

Large surface/volume ratioLarge surface/volume ratio• rapid fluid lossrapid fluid loss• increased heat loss increased heat loss hypothermia hypothermia

Delicate balance between dehydration Delicate balance between dehydration and overhydrationand overhydration

Immature immunological response Immature immunological response sepsissepsis

Always consider possibility of child abuseAlways consider possibility of child abuse

Geriatric BurnsGeriatric Burns

Decreased myocardial reserveDecreased myocardial reserve• fluid resuscitation difficultyfluid resuscitation difficulty

Peripheral vascular disease, diabetesPeripheral vascular disease, diabetes• slow healingslow healing

COPDCOPD• increases complications of airway injuryincreases complications of airway injury

Poor immunological response - SepsisPoor immunological response - Sepsis % mortality ~= age + % BSA burned% mortality ~= age + % BSA burned

burn injuries by donald hudson, d.o., facep/acoep

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