Download Burn Management - North Country EMS Program Agency

Burn Management – ALS
Jason D. Haag, CCEMT-P
Objectives:
• How to evaluate serious burn patients.
• Determining magnitude and severity of burns.
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How to identify treatment priorities.
Airway and ventilation management.
Which patients need burn centers.
Why so much fluid?
Inter-facility burn transports.
Some caveats:
• We will only focus on the initial 24 hours of burn care.
• Initial management of ABC is key.
• Assessment is equally important.
Initial Assessment and Management
Initial Assessment and Management:
• Primary and Secondary Assessments
• Application of the “Rule of Nines.”
• Differentiate between full and partial thickness burns.
• Understand criteria for burn center patients.
Primary Assessment:
• Burn is Trauma – assessment with be similar
• ABCDE
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Airway maintenance with C-Spine consideration
Breathing/Ventilation
Circulation/Bleeding Control
Disability (neuro deficits)
Exposure (remove clothing, keep warm)
Airway…airway…airway…airway…airway
• Requires immediate assessment and intervention.
• May include:
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Chin lift
Jaw thrust
OPA
ETT/SGA for ALS
• Cervical spine immobilization should be maintained in patients
with suspected spinal injury due to MOI or AMS.
Breathing:
• Adequate function of the lungs, the chest wall and diaphragm are
all required in primary survey.
• Listen to breath sounds bilaterally
• Determine adequacy, rate and depth of breaths
• Supplemental oxygen to all patients
• Carbpxyhemoglobin
• Full thickness, circumferential burns to the thorax must be monitored.
• Swelling may impede ventilation
Circulation:
• Include in assessment:
• Blood pressure, pulse rate, unburned skin color
• Immediate large bore IV access with fluid administration.
• Burned skin may be used, not preferred.
• IO access
• Assess parts with full thickness burns for circulation and deficits.
• Decreased sensation, diminished distal pulses, delayed capillary refill
• Caused by subeschar edema
Disability:
• Typically alert and oriented post injury. If AMS is present other
injuries may be present:
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CO Poisoning
Pre-existing conditions
Hypoxia
Substance abuse
• Determine AVPU on assessment:
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Alert
Voice
Pain
Unresponsive
Exposure:
• All unburned clothing and jewelry is removed
• Maintaining body temperature is paramount
• Warm ambulance and cover with dry sheets and blankets after
assessment
• Hypothermia is a common complication
• Warm NaCl (37-40˚C) may be used
Secondary Assessment
• Follows primary assessment and identifies needs for resuscitation
have been addressed
• Is a head to toe evaluation
• Other injuries may be present in addition to the burn
• Identify pre-existing injuries/illnesses by exam/history
• Complete neurologic examination
History:
• Obtain as much information as possible about the initial incident
• Management and transport destination dictated by:
• Mechanism
• Duration
• Severity of Injury
History:
• Circumstances of injury must be obtained:
• Flame:
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How did the burn occur?
Did clothes catch fire?
How extinguished?
Explosion?
Structure fire?
How did patient escape?
Others killed at scene?
MVA?
Care fire?
Injuries consistent with burns?
Inside or outside?
Time to put fire out?
Gasoline or other fuels?
Was patient thrown?
Patient in smoke filled room?
Jump? How high?
Unconscious at scene?
Damage to vehicle?
Other injuries?
Possible abuse?
History:
• Scald:
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How did it happen?
What was the liquid?
Water heater temperature?
Speed of clothing removal?
Who was with the patient?
Where did scald occur?
• – bath, sink, shower?
• Abuse patterns?
Temperature of liquid?
How much liquid involved?
Was patient clothed?
Burned area cooled?
How soon was care sought?
History:
• Chemical:
• What was the agent?
• Duration of contact?
• Is there and MSDS available?
• How did exposure occur?
• Decontamination done?
• Was there an explosion?
History:
• Electrical:
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What kind of electricity?
Thrown or fall?
LOC?
Duration of contact?
Estimated voltage?
CPR at scene?
Defibrillation?
Medical History:
• Considerations:
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Pre-existing illness or disease
Medications/EtOH/drugs
Allergies
Tetanus immunization
SAMPLE History:
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Signs/Symptoms
Allergies
Medications
Past History
Last Oral Intake
Events leading to injury
Physical Exam:
• Head to Toe Exam:
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Head
Maxilofacial
C-Spine/Neck
Chest
Abdomen
Perineum
Posterior
Musculoskeletal
Vascular
Neurologic
Burn Severity:
• Severity of burns is determined two ways:
• Body surface area involved
• Depth of the burn
• Other factors such as age, pre-existing conditions, and surgical
problems
• Complications from burns to areas of the face, hands and genitals
Burn Severity:
• Extent of the burn:
• For 2nd and 3rd degree burns the “Rule of 9’s” is used, meaning most
anatomic locations of the adult body represent 9% of the total body surface
areas.
• Differs in children as the TBSA of their head is bigger and the TBSA of their
lower extremities is smaller.
Rule of 9’s - Adult
Rule of 9’s – Pediatric
Burn Severity:
• Scattered Burns/Limited Extent:
• Patient’s hand (with fingers) represents about 1% of their TBSA
• Using their hand to estimate, the extent of scattered burns can be
determined.
• Also known as the “Hand Rule.”
Burn Severity:
• Depth of a burn:
• Depth of tissue damage from a burn depends on four
factors:
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Temperature
Thickness of the dermis
Contact duration
Blood supply
• Special considerations for the very young and very
old.
• May be deeper and more severe than they appear.
Management Principles:
• Universal Precautions
• Stop the burning process
• Remove clothing from the affected area
• Flush chemicals if present
• Stop electrical current when safe
• Fluid resuscitation
• Parkland Formula: 2-4ml NaCl x Weight(kg) x %BSA
• First 8 hours administer half of calculated volume
• Next 8 hours 25% of the calculated volume is administered. 25%
in last 8 hours.
• IV rate is adjusted for urine output
Management Principles:
• Vital Signs:
• Monitor frequently at regular intervals
• NG Tube:
• If more than 20% TBSA prone to gastric dilation and ileus
• Urinary Catheter:
• Urine is used to determine adequate fluid replacement
• Extremity Perfusion:
• Monitor distal blood flow as eschar edema may inhibit arterial
and vascular flow. An escharotomy may be needed.
What’s an escharotomy?
Management Principles:
• Continued Ventilatory Assessment:
• Circumferential chest or abdominal burns can impede ventilation.
Escharotomy may be necessary. Pediatrics have a more pliable rib cage
making it less common for them.
• Pain Management:
• Morphine and Fentanyl are indicated for burn patients. Fluid shift can make
IM absorption ineffective. IV is a must. Be careful of dosage as patient may
already be hypotensive.
Initial Wound Care:
• Thermal Burns:
• Cover area with clean, dry sheet. This causes moving
air from causing pain in partial thickness burns.
• Ice/wet dressings should never be directly applied.
Frostbite is a common side effect.
• Except in minor 1st degree (sunburn) cold application
should not be done.
Initial Wound Care:
• Electrical Burns/Injuries:
• Current passing through a patient can cause cutaneous
burns as well as extensive internal burns/injuries.
• Effect on cardiac system is a paramount concern.
Serious dysrhtyhmias remain a concern even if stable.
• Cardiac monitoring is required.
• Even if no outward serious injury is present, internal
injury is likely.
Initial Wound Care:
• Chemical Burns:
• Protect yourself before decontaminating or caring for a
patient.
• Any chemical agent must be immediately flushed from body
with high amounts of water.
• Powdered chemicals should be brushed away prior to flushing.
• Contaminated clothing will be removed.
• Eye injuries must be flushed continuously until ordered to stop
by a physician.
Burn Center Characteristics:
• A burn center is a hospital based unit that has made an
institutional commitment to care for burn patients.
• Staffed with experts in acute burn care and burn rehab.
• Educates other healthcare providers regarding burn care
and is involved in burn care research.
• Dedicated unit to burn patients.
Burn Center Criteria:
• The American Burn Association has deemed the following injuries
to be referred to a burn center (Which may differ from your
regional trauma centers.):
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Partial thickness burns >10% TBSA
Burns involving the face, feet, hands, genitals, perineum, or major joints.
3rd degree burns in any age group.
Electrical burns including lightening.
Chemical burns.
Inhalations injury.
Burn Center Criteria:
• Burns in patients with pre-existing medical problems that could
make management, recovery and mortality more severe.
• Burns and associated trauma with burns causing the greatest risk
for M and M. Burns will be stabilized and then transported to an
appropriate trauma center.
• Burned children in hospitals not capable of caring for burns or
pediatrics.
• Burns in patients with special mental/social needs.
• When in doubt, consult Medical Control.
Airway Management and Smoke Inhalation
Injury:
Airway Management:
• Objectives:
• Discuss pathophysiology of inhalation injury.
• List three types of inhalation injury.
• Indications for early airway management.
• Discuss principles of management.
• List special considerations for children with inhalation
injuries.
Pathophysiology:
• CO Poisoning:
• Most fire deaths are due to asphyxiation or carbon
monoxide poisoning
• Carboxyhemglobin levels of 50-70% or more are found
in these patients
• Survivors of inhalation injuries are most at risk for CO
poisoning
• CO has a binding affinity to hemoglobin 200 times that
of oxygen
• Will cause hypoxia
Pathophysiology:
• CO Poisoning:
• Immediate threat is to the brain
• 40-60% carboxyhemoglobin cause LOC and obtundation
• 15-40% carboxyhemoglobin cause varying degrees of
CNS dysfunction
• 5-10% of carboxyhemoglobin found in smokers and
those around heavy traffic. This level is rarely
symptomatic.
Pathophysiology:
• CO Poisoning:
• Typical finding is cherry red skin, only occurs in 50% of
patients with high CO levels.
• May have no significant exam findings.
• Pulse oximetry is not useful as it measures the
oxygen-hemoglobin bind and not the level of
carboxyhemoglobin.
• Blood labs are essential to determine this and can
only be done in-hospital.
Pathophysiology:
• Upper Airway Injury:
• Thermal burns are typically limited to the upper airway
• Due to heat absorption being so efficient most damage occurs
above the true vocal cords
• Damage to pharynx is usually severe enough to cause an upper
airway obstruction causing issues during resuscitation
• In un-resuscitated patients this may not be an issue until fluid
replacement has occurred
• Early ETT placement is paramount in these patients
Pathophysiology:
• Lower Airway Injury:
• Injury below the glottis is almost always chemical
• Smoke contains chemical such as sulfur oxides,
aldehydes, and phosgenes which cause epithelial
damage
• Prolonged smoke exposure can effect not only the
great airways, but smaller airways and terminal
bronchi as well
Pathophysiology:
• Physiologic changes after an injury in lower airway
include:
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Impaired cilia activity
Erythema
Hypersecretion
Edema
Ulceration of mucosa in airway
Bronchi/Bronchiole spasms
Impairment of immune defenses
Pathophysiology:
• Tracheobronchitis causing severe spasm and wheezing can happen minutes to
hours post injury.
• Higher doses of smoke will cause higher COHb levels and respiratory distress
in early post-injury hours.
• Inhalation injury and damage are unpredictable even with history and exam.
• Chest x-rays often present normal as well.
• Must observe for at least 24 hours.
• Muscosal sloughing may occur as late as 4-5 days.
• Do not withhold appropriate fluid for these patients – this can cause more
harm than good.
Initial Management:
• O2 therapry and Initial Airway Management:
• If CO poisoning or airway injury is suspected apply 100% oxygen
immediately.
• Strido or other noises indicate impending upper airway
obstruction. ETT should be placed immediately. May require
RSI.
• If indicated maintain C-spine stabilization while maintaining
the airway.
• Determine placement with continuous waveform EtCO2
monitoring. Correct displacement immediately
Intubation Considerations:
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Size of burn >40-50% TBSA
Extensive facial burns
Burn inside mouth
Edema of risk for
Signs of airway obstruction
Difficulty swallowing
Hoarseness
Stridor
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Changes in voice
Use of accessory muscles
Panicked appearance
Inability to protect airway
Inability to handle secretions
Respiratory fatigue
Poor oxygenation/ventilation
Need for large doses of
narcotics
Assessment and Management:
• General Assessment Findings (after securing ABCs):
• History of event:
• History of unconsciousness
• Chemicals involved
• Occurrence in enclosed space
• Physical findings:
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Carbonaceous sputum
Facial burns, singed nasal hair
Hypoxia
Respiratory distress
Hoarse voice, adventitious sounds
Pharyngeal swelling
Inability to swallow
Treatment for Specific Injuries:
• CO Poisoning:
• Half-life of CO in the blood is ~4 hours on room air
and is decreased to 1 hour on 100% oxygen.
• Hyperbaric oxygen has been proven effective.
• Transport a burn center is not delayed for a
hyperbaric center.
• 100% oxygen will suffice for CO removal.
Treatment for Specific Injuries:
• Upper Airway Injuries:
• Progresses very rapidly.
• Patients with pharyngeal edema, burns, hoarseness, or
stridor likely have and upper airway obstruction and
should be intubated prior to arrival at a burn center.
• Physical findings of the potential airway injury and extent
of cutaneous burns should be used for the continuing
assessment.
• ABG levels are not useful in these cases.
Treatment for Specific Injuries:
• Lower Airway Injuries:
• Inhalation injuries present chiefly with bronchial and bronchiolar injury –
bronchorrea with expiratory wheezing.
• Should be quickly intubated to manage secretions, relieve dyspnea, and
endure adequate oxygenation/ventilation.
Treatment for Specific Injuries:
• Lower Airway Injuries:
• In some instances injury occurs at the level of gas exchange
• Often delayed onset with early manifestation being impaired arterial
oxygenation
• Must be monitored closely to assess need for mechanical ventilation
• ]Circumferential thoracic burns may require escharotomies to improve
ventilation
• Avoid steroid use in these patients
Treatment of Specific Injuries:
• Inhalation Injury in Pediatric Patients:
• Peds airways are relatively small. Upper airway obstruction
will occur more rapidly.
• Proper ETT size and proper placement must be done with great
efficiency and care.
• Peds rib cages are not yet rigid and sternal retraction indicates
a need for ETT placement.
• Peds can also become rapidly exhausted.
• Decision to place and ETT in the pediatric patient should come
before an adult.
“Failure to manage the airway is the leading cause
of preventable death in children.”
-Ken Kelly, Paramedic, Instructor
EOW March 9, 2014
Shock and Fluid Resuscitation
Shock and Fluid Resuscitation:
• Objectives:
• Post-burn hemodynamic changes
• Post burn fluid requirements
• Physiologic monitoring
• Common complications of burn injury and
resuscitation therapy
• Patients requiring special fluid management
Introduction Matter:
• Proper fluid replacement is critical to an extensive burn
patient’s survival.
• Aimed at maintaining fluid perfusion and organ
functions. Must avoid complications of inadequate or
excessive fluid therapy.
• Must understand local and systemic effects of burn injury
in early post-burn period.
• Burn shock is readily preventable.
Systemic Effects of Burn Injury:
• Thermal injury quickly manifests with an increase in PVR and a
decrease in cardiac output.
• Initial changes appear unrelated to hypovolvemia and are
attributed to neurogenic and humoral effects.
• Drops in blood pressure reflect edema formation around the burn,
decreased blood volume, and falling cardiac output.
• The higher the TBSA, the higher the magnitude and duration of
systemic response.
Fluid Resuscitation:
• Goal:
• Mission is to maintain tissue perfusion and organ functions.
• Must avoid complications of ineffective or excessive fluid resuscitation.
Fluid Resuscitation:
• Results of Excessive Resuscitation:
• Edema in dead/injured tissue reaches highest levels in
the second 24 hours post burn.
• Excessive volume, or inappropriate post-resuscitation
fluid management increases edema formation and will
compromise blood-flow.
• Patients most sensitive to fluid are:
• Children
• Elderly
• Pre-existing cardiac disease
Fluid Needs In Immediate Post-Burn Period:
• Fluid needs are related directly to burn and body size.
• Patient can be weighed or a pre-burn weight estimate
will suffice.
• Percentage of body area affected is estimated by Rule of
9s.
• Reliable peripheral veins should be used for access,
under burned skin may be used if needed.
• A central line or IO access may be necessary.
• Patient less than 8 should get IO access.
Resuscitation Fluid:
• With increased capillary permeability colloid content has little
influence and retention during the initial post burn time.
• Crystalloid fluids must be used for initial resuscitation of burn
patients.
Calculation of Fluids:
• Adults: LR/NaCl: 2-4ml x kg x TBSA
• Children: LR/NaCl: 3-4ml x kg x TBSA
• Infans/Children: 5% Dextrose at a maintenance rate in addition to
fluid resuscitation formula.
Calculation of Fluids:
• Infusion rate is regulated so ½ volume is
administered in the first 8 hours post-burn.
• The remaining half of the volume is delivered
over the next 16 hours of the initial burn day.
• IV rate should be adjusted for adequate urine
output.
• Adults: 0.5ml/kg/hr (30-50ml/hr)
• Children: 1ml/kg/hr
Pediatric Patients:
• Greater surface area of pediatrics requires higher
amounts of fluid resuscitation.
• Surface area: body mass defines a lesser intravascular
volume per unit surface area burned.
• Causes pediatrics to be susceptible to fluid overload and
hemodilution.
• Hypoglycemia may occur due to limited glycogen stores.
Regular glucose testing and replacement is important.
Fluid for Needs More than Formula Predicted:
• Predictions are just that – predictions.
• Individual patient response should serve as a guide to
fluid administration.
• Need for more fluid is common in:
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Associated injuries
Electrical injuries
Inhalation injuries
Delayed resuscitation
Prior dehydration
EtOH/Drug dependencies
Deep burns
Monitoring Resuscitation:
• Actual administered fluid should vary from calculated volume
based on patient response.
• Cardia output should return to normal in 12-18 hours.
• If no return consider myocardial infarction of insufficiency.
• Anxiety and restlessness can indicate hypoxia and/or hypovolemia.
Hourly Urinary Output:
• Measured with indwelling catheter:
• Adults: 0.5ml/kg/hr (30-50ml/hr)
• Children less than 30kg: 1ml/kg/hr
Blood Pressure/Heart Rate:
• Manual BP can be misleading in presence of edema.
• Falsely ready hypotension can cause fluid overload.
• Aterial BP can be inaccurate as well due to
vasoconstriction.
• Heart rate has limited usefulness.
• Rate of 100-120 is common in adults with low blood
volume.
• Tachycardia in pediatrics depends on normal heart rate.
Burn Wound Management
Burn Wound Management:
• Objectives:
• Determine full-thickness or partial-thickness burns.
• Management of patients with burns in special areas
Burn Wound Management:
• Treatment of other life threatening and limb threatening injuries
should take priority.
• Move to burn management after stabilizing life threats.
• Burn management should be a close second.
• Ultimately, survival and recovery depend on burn management.
Burn Wound Management:
• Skin A and P Review:
• Structure: Two layers – Dermis and Epidermis
• Epidermis is outer, thinner layer
• Dermis is deeper, thicker layer
• Contains sweat glands, hair follicles. And sensory fibers.
• Function: Four functions crucial to survival:
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Protection from infection/injury
Protection from body fluid loss
Regulation of temperature
Sensory contact
Burn Wound Management:
• Depth determines level of care needed
• Described as 1st, 2nd, 3rd or 4th degree
• 1st Degree: Superficial, involves only epidermis.
• Skin is red and sensitive
• 2nd Degree: Involves epidermis and part of dermis.
• Skin is red, edematous and blistered. Nerve endings damaged causing pain.
• 3rd Degree: Full thickness that destroys both layers
• White, charred or translucent appearance. Nerves destroyed, sensation lost
• 4th Degree:
• Involves all tissue to bone and great vessels. Requires emergent surgical
intervention
Burn Wound Management:
• Specific Anatomical Burns:
• High level of concern and burn center
treatment is needed for burns to face, feet,
eyes, axilla, perineum, hands or major joints.
Burn Wound Management:
• Facial Burns:
• Considered a serious injury
• High possibility of airway injury/burn
• High vasculature often causes increases edema
• Elevate head and trunk to 30 degree angle if not
hypotensive
• Clean with sterile water or saline. Cover eyes.
Burn Wound Management:
• Eye Burns:
• Assess quickly as rapid swelling will not allow for it
later
• Chemical burns should be continuously flushed
• Do not cover eyes in initial acute treatment
Burn Wound Management:
• Ear Burns:
• Examine external canal and drum prior to swelling
• Injury from explosion will often have tympanic membrane
rupture
• Avoid additional trauma and refrain from using occlusive
dressings or placing head on a pillow
Burn Wound Management:
• Hand Burns:
• Minor burns result in temporary inconvenience and disability
• More severe burns likely to cause permanent loss of function
• Determine vascular status
• Elevate above heart, activity each hour post burn, and avoid
dressings
Burn Wound Management:
• Foot burns:
• Assess circulation and neurologic functions hourly
• Minimize edema by elevating the extremity
• Treat like a hand burn
Burn Wound Management:
• Genitalia and Perineum:
• Penile burn requires immediate catheterization – transport to a local
hospital prn for placement
• No specific treatment for scrotal swelling
• Perineal burns are difficult to manage, however no specific acute
management
• All require burn center treatment
Electrical Injury/Burn:
• Objectives:
• Understand pathophysiology of electrical injuries
• Understand specialized assessment techniques for
patients with an electrical injury
• Understand management of a patient with an
electrical injury
Electrical Injury/Burn:
• Often well hidden – small entrance/exit wounds do not represent
massive internal injuries
• Account for 3% of burn center admissions and cause 1,000 deaths
annually
• Typically work related incidents
• Divided in to high and low voltage
• Injury caused by current, arc, flash and clothing ignition
Electrical Injury/Burn:
• Pathophysiology:
• When body becomes part of the electrical circuit
injury is determined by strength of current and
duration.
• Ohm’s Law – Current proportional to voltage and
inversely proportional to resistance.
• Tissue injury is from energy conversion to heat.
• Skin is the only provider of electrical resistance.
• Injury happens after resistance is overcome.
Electrical Injury/Burn:
• Pathophysiology:
• Suggestions of electrical injury include:
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Loss of consciousness
Paralysis of extremity
Mummified extremity
Loss of peripheral pulse
Flexor surface burns
Electrical Injury/Burn:
• Pathophysiology:
• Current: Measured in Amps (A)
• Alternating Current (AC) – reverse of electron flow every half
cycle
• Direct Current (DC)
• AC has replaced DC in most applications except lighting and
batteries
• AC is more dangerous due to cardiac fibrillation and respiratory
musle paralysis
Electrical Injury/Burn:
• Types of Injury:
• Current: AC power flows back and forth to anatomical point.
No entry or exit wound. DC travels in on direction from
entrance to exit wounds.
• Arcing: Ionization of air between 2 conductors. Can be as hot
as 4,000 degrees C.
• Flash: Can result from ignition of clothing or power source.
May occur without tissue injury.
Electrical Injury/Burn:
• Lightning Strike:
• Risk is 1:280,000
• Kills 80 – 100 people annually with 30% mortality and
70% survivors with severe complications
• Lightning is DC and may exceed 200,000 volts
• Typically no deep burns, however superficial injury
• Risk for significant cardiac and neuro damage
• Can directly cause asystole with no fibrillation phase
Electrical Injury/Burn:
• Management:
• Primary Survey:
• Airway – C-spine precautions prn
• Breathing
• Circulation
• Disability – Determine GCS and pupillary response
• Exposure – Protect from hypothermia
Electrical Injury/Burn:
• Management:
• Secondary Survey:
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Head-to-toe physical exam
Remove all clothing and jewelry
Identify all clothing and jewelry
Identify contact points
Estimate surface burn area
Detailed neuro exam
Check from orthopedic involvement, internal injury and
compartment syndrome
Electrical Injury/Burn:
• Management:
• Resuscitation:
• Two large bore IVs
• Initiate fluid replacement using the Parkland
Formula to maintain urine output
• Cardiac monitoring – continuous 12 leads
• Continuously assess peripheral CMS
Electrical Injury/Burn:
• Cardiac Arrest:
• Treat VF, asystole and other dysrhythmias by current
ACLS algorithms
• With burns to face and neck consider early ETT
Chemical Burns
Chemical Burns:
• Objectives:
• Identify 3 major classes of potentially dangerous
chemicals and their MOA
• Initial management of chemical burns
• Factors that contribute to severity
• Identify and describe treatment for special chemical
burns
• Initial management of chemical eye injuries
• Identify common chemical warfare agents
Chemical Burns:
• Over 500,000 chemical in the US with over 30,000
being designated as hazardous
• 60,000 people require medical attention annually
• Chemical burns represent 2-6% of burn unit
admissions
• Extent of burns is directly related to time
between injury and treatment
• Should be transported to a burn center
Chemical Burns:
• Classifications:
• Alkalis:
• Include hydroxides, carbonates and caustic sodas
• Contain sodium, potassium ammonium, lithium, barium and
calcium
• Compounds are oven cleaner, drain cleaner, fertilizers, and
industrial cleaner
• Cause bond in cement and concrete
• Wet cement has a pH of 12 which will cause severe burns
• Damage to tissue by causing liquification necrosis and
allows for a deeper burn
Chemical Burns:
• Classifications:
• Acids:
• Found in home and industry
• Common acids are hydrochloric, oxalic, hydroflouric,
muriatic, and sulfuric acid
• These are found in bathroom cleaners, rust removers,
swimming pool treatments, and industrial strength drain
cleaners
Chemical Burns:
• Classifications:
• Organic Compounds:
Include phenols, creosote, and petroleum products
Cause contact chemical burns and systemic derangements
Phenols are in chemical disinfectants
Petroleum, gasoline and creosote are found in homes,
businesses and industry
• Cause skin and tissue damage due to fat solvent properties
• When absorbed is toxic to kidneys and liver
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Chemical Burns:
• Severity Determinants:
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Agent
Concentration
Volume
Duration of Contact
Mechanism of Action
Concentration of the chemical causes depth of injury and volume
affects extent of surface involved. Immediate irrigation reduces
concentration and duration of contact.
Chemical Burns:
• Treatment:
• Universal precautions for all chemical burn patients
• Initial treatment mist be removing saturated clothing,
brushing agent off skin, and continuous irrigation with
water until ED arrival
• Efforts to neutralize should not happen due to
possible heat generation
• Support ABCs
• Attempt to identify agent(s) involved
Chemical Burns:
• Eye Injuries:
• Alkali injuries are twice as frequent as acid injuries
• Maintain continuous irrigation from scene to ED
• Presents with swelling and eye spasms
• Hydroflouric Acid:
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Used in industry frequently and is a weak acid
Low concentration causes pain in 16-18 hours
High concentration causes immediate pain
Will cause hypocalcemia. IV and cardiac monitoring essential
Chemical Burns:
• Phenol Burns:
• Acidic Alcohol – not soluble in water – disinfectant/solvent
• Causes coagulation necrosis of proteins
• Irrigate continuously with water
• Petroleum Burns:
• May cause a full thickness burn which may not be immediately
visible
• High absorption can cause MSOF and death
• Examine body thoroughly for exposure
• Symptoms peak within 24 hours
Chemical Burns:
• Tar Burns:
• Essentially a contact burn with chemical involvement
• Colling the molten tar is paramount
• Cover with petroleum gauze dressing
• Anhydrous Ammonia:
• Common fertilizer or industrial refrigerant
• Used in Methamphetamine production
• Caused blistering to skin and ALI if inhaled
Chemical Warfare Agents:
• Large role in M+M and WWI and used in many
terrorist attacks
• Typically vesicants and nerve gasses are used
• Produce cutaneous toxicity, systemic toxicity,
pulmonary, hepatic and neurologic damage
• Treat as other chemical injuries
• Aggressive airway management prn
• In MCIs isolate and follow Haz-Mat guidelines
Pediatric Burn Injuries
Objectives:
• A child is different from an adult in:
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Size
Skin thickness
BSA and temperature regulation
Metabolic rate
Psychological and development issues
Principles of management for heat, electrical and chemical
burns
Recognize and report burns as needed due to child abuse
Statistics:
• More than 2,500 children die annually from thermal
injury
• Nearly 10,000 children have a permanent disability from
burns
• Scalds are most common under 3 years old
• Flames burns more common in older children
• Scalds often caused by abuse
Pathophysiology:
• Body Surface Area:
• Children have a great surface area compared with
weight
• More in contact with environment resulting in greater
fluid needs and water loss than adults
• Reach adult surface : weight ratio by 15
• Under age 2 has thinner skin
• Most burns end up full thickness
Pathophysiology:
• Temperature Regulation:
• Heat generation by shivering is minimal due to low
muscle mass
• Less than 6 months old regulation is based on
metabolism, not shivering
Pathophysiology:
• Skin Thickness:
• Infants tolerate 1/3 of heat exposure than adults can
• Common home hot water temperature is 140 degrees
F and causes tissue destruction in under 5 seconds
• At 160 degrees full thickness is instant
• Homes with children should have water set at no more
than 120 degrees
Initial Evaluation:
• History and Physical:
• Typically mirror method of an adult
• Immunization and medical history are very important
• Ensure injury/burn pattern matches story
• High suspicion of abuse, especially if under 4 years old
Resuscitative Measures:
• Airway:
• The youner the child and larger the burn, the more
likely ETT will be required
• Anatomy is much different:
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Glottis is anterior
Epiglottis is more acutely angled
Intubation if difficult if not experienced
Have back up devices ready
Be prepared for surgical
Narrowest point is cricoid ring, not glottis
Resuscitative Measures:
• Circulatory System:
• 10% greater BSA should be transported to a burn
center
• After securing airway, ensure IV/IO access an fluid
administration is done
• Fluid calculation follows the Parkland Formula
• Is often over/underestimated based on BSA calculation
Resuscitative Measures:
• Circulatory System:
• Resuscitation fluid formula (First 24 hours):
• Initial volume (ml): 3-4ml x weight(kg) x BSA
• Maintenance
• First 10 kg of body weight – 100ml/kg over 24 hours
• Second 10kg of body weight – 50ml/kg over 24 hours
• Each kg above 20kg – 20ml/kg over 24 hours
As always, titrate fluid to effect. Monitor urine output
Resuscitative Measures:
• Wound Care:
• Initial management by stopping the burning process
• Remove all clothes to examine covered areas
• Cover with clean linen
• Conservation of body hear is paramount in pediatrics
Resuscitative Measures:
• Child abuse:
• Under 4 years old should be considered as child abuse
until proven otherwise
• Document – photographs, written reports, etc.
• Suspicion triggered when:
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Injury pattern not consistent with given history
Line of demarcation is smooth
Sock or glove distribution
Long delay from injury to seeking treatment
Pain Management:
Analgesiea:
• Burns hurt
• Analgesia should not take precedence over stabilizing
life threats to ABCs
• Follow local protocol for pain management
• Monitor respiratory and hemodynamic status
• Ketamine may be desirable for dissociation due to
discomfort
• More hemodynamically stable than opiates/benzos
Questions/Comments:
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