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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
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
�� 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
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
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?
Full thickness with partial around edge. Deep partial
thickness may heal in 2-3 months with severe scarring.
Full thickness – only area not burned is under thigh (pink area)
*Note – Hand burns at top of picture
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
Non-burned
areas
Chemical burn – burning to legs & feet around
laces of work boot (same pt as previous slide)
Sources Electrical Burn
�� Low voltage injuryLow voltage injury
�� High voltage injuryHigh voltage injury
�� Lightning injuryLightning injury
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.
Partial to full thickness
*Note – electrical burns between entry and exit wound, work from the inside to the outside
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.)
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.
*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
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
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
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
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…
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”.
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?
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