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Ch. 29 Burn Emergencies

Marissa Alvarez EMT BASIC College English 55 cards

Ch. 29 Burn Emergencies

Cards in this deck (55)

  1. 1The Skin: Structure and Function StructureThe skin is comprised of three layers:
    The outermost layer is the epidermis which provides a watertight and resilient barrier from the external environment.
    The second layer, the dermis, contains small capillary beds as well as the sensory structures of the skin.
    The innermost layer, the subcutaneous layer, is composed of fatty connective tissue and contains larger blood vessels.
    The layers range in thickness from one cell to several layers of cells.
  2. 2The Skin: Structure and Function FunctionThe skin serves multiple functions:
    Provides a physical barrier against the external environment
    Provides a barrier against infection
    Provides protection from bacteria or other harmful agents
    Insulates and protects underlying structures and body organs from injury
    Aids in the regulation of body temperature
    Provides for sensation transmission (hot, cold, pain, and touch)
    Aids in elimination of some of the body's wastes
    Contains fluids necessary to functioning of other organs and systems
  3. 3What do patients die from?Most burn patients who die in the prehospital setting will die from an occluded airway, toxic inhalation, or other trauma, and not from the soft tissue trauma of the burn itself.
    Given this, the EMT should first establish and maintain a patent airway, adequate ventilation, and adequate oxygenation, and ensure any life - threatening bleeding has been controlled.
  4. 4Burn Systemic EffectsThe immediate effects of a burn injury are typically severe pain, and potential airway, breathing and circulatory compromise.
    Hours after the initial injury, however, other body systems may experience severe compromise that may be severe enough to cause death. These include the circulatory, respiratory, renal, musculoskeletal, nervous and gastrointestinal systems.
  5. 5Circulatory EffectsBurns result in extreme fluid loss and excess stress on the heart. This is referred to as BURN SHOCK which typically develops after the first few hours of the initial injury.
    Burn shock CAUSES:
    -Capillaries to leak fluid and protein
    -Loss of plasma proteins which disturb the normal fluid balance of the entire circulatory system
    -Fluid leaks from undamaged capillaries
    -Massive fluid shifts from intravascular system to interstitial space which results in a relative HYPOVOLEMIA
    -Edema resulting in extensive body swelling
    ***Large volumes of fluid replacement are required
  6. 6Respiratory EffectsSwelling of the face or throat may obstruct airway
    Inhalation of superheated air may cause larynx to swell and fluid to accumulate in lungs
    Smoke and toxic gas may cause cardiac arrest
    **Circumferential chest burns may restrict chest expansion
  7. 7Renal EffectsFluid loss results in decreased circulation to kidneys
    Wastes accumulate in blood from cell destruction
    Rhabdomyolysis (myoglobin from muscle destruction can obstruct the kidneys and result in acute renal failure)
    Renal failure
  8. 8Nervous and Musculoskeletal System EffectsBurns can destroy nerve endings in the burn area
    May cause loss of function, muscle wasting, and joint dysfunction from scarring
  9. 9Gastrointestinal EffectsBlood commonly diverts from this system to other organs as a result of the burn shock following the injury
    Nausea/vomiting common in burns > than 10% BSA
    Diminished perfusion means diminished absorption and processing of food leading to chemical imbalances in the blood
  10. 10Classifying BurnsBurns are classified according to the depth of injury.
    Severity of a burn is a calculation of both the burn type, and the extent of the burn.
  11. 11The three primary classifications are: Superficial (1°):redness, some pain, only involves outer layer of skin (the epidermis)
  12. 12The three primary classifications are: Partial Thickness (2°):involves epidermis (top layer) and part of the dermis (2nd layer), intense pain, surface of skin mottled white to red with or without blisters
  13. 13The three primary classifications are: Full Thickness (3°):involves epidermis, dermis, and even some of the subcutaneous layer; have eschar of skin
  14. 14Superficial BurnsA superficial burn is an injury that involves only the epidermis. Usually a superficial burn is caused by a flash (a sudden occurrence of heat or flame lasting only a few seconds), hot liquid, or the sun.
    The skin will appear pink to red and will be dry. In some cases there may be a slight swelling, but there will be NO BLISTERS. The skin will be soft and tender to the touch.
    Although superficial in nature, these types of injuries may be very painful since the underlying pain receptors in the dermis of the skin are still INTACT.
    Superficial burns, generally, will take several days to heal, and not require much emergency medical care if only a small area is injured. The injury may cause the epidermis to peel but not cause any scarring.
    Examples of superficial burns include sunburn or a minor scald injury.
  15. 15Partial Thickness BurnsA partial thickness burn involves not only the epidermis but portions of the dermis as well.
    Partial thickness burns occur from contact with fire (flame or flash), hot liquids or objects, chemical substances, or the sun. I
    n addition, damage to the small blood vessels causes plasma and tissue fluid to collect between the layers of skin and FORM BLISTERS. Since pain receptors are still intact, the patient will complain of significant pain from the burn.
    Partial thickness burns are further classified as superficial partial thickness and deep partial thickness burns.
  16. 16Partial Thickness Burns 1) Superficial Partial Thickness BurnsThese burns have:
    Thin-walled blisters
    Pink, moist skin
    Skin is soft and tender to the touch
  17. 17Partial Thickness Burns 2) Deep Partial Thickness BurnsThese burns have:
    Thick-walled blisters that often rupture
    Skin that is red and blanched white
    Intense pain from nerve ending damage
    Poor capillary refill due to increased edema
    These burns are often caused by thermal flame or hot fluid scalding such as hot water.
  18. 18Full Thickness Burns A full thickness burn involves all layers of the skin. This type of burn results from contact with extreme heat sources such as hot liquids or solids, flame, chemicals, or electricity.These burns have:
    Dry, hard, tough, and leathery skin (eschar)
    May appear white and waxy to dark brown or black and charred.
    Not much pain because nerve endings are destroyed
    While pain may be minimal or nonexistent in the immediate area of the full-thickness burn, in most such injuries there will be surrounding areas of partial thickness and/or superficial burns that may cause intense pain.
    Full thickness burns are often evident in patients who have been trapped in a confined space with flames or who have been exposed to a high heat source or chemical contact.
    Some full thickness burns may also be categorized as fourth-degree burns. A fourth-degree burn is a very deep burn that extends completely through the epidermis and dermis and deep into the tendons, ligaments, muscle, bone, blood vessels, and nerves.
    These burns are typically associated with electrical injuries and require extensive skin grafting to allow the site to heal.
  19. 19Inhalation BurnsThese burns are very serious and may rapidly produce airway swelling resulting in complete airway occlusion.
    Signs and symptoms include:
    -Singed nasal hairs
    -Facial burns
    -Burned specks of carbon in the sputum
    -A sooty or smoky smell on the breath
    -Respiratory distress accompanied by restriction of chest wall movement, restlessness, chest tightness, stridor, wheezing, difficulty in swallowing, hoarseness, coughing, and cyanosis
    -Presence of actual burns of the oral mucosa
  20. 20Severity: Burn Injury LocationJust as the DEPTH of the burn injury and its BODY SURFACE AREA are important, so too is the LOCATION of the burn.
    Injuries to certain body areas are more critical than those to other areas. Burns of the face are considered critical because of the potential for respiratory compromise as are injuries to the eyes or ears; hands and feet because of the potential for loss of function; genital or groin region because of the potential for loss of genitourinary function and increased chances for infection.
    Finally, burns that occur to regions of the body where there is major JOINT function (for example hips and shoulders), may be considered critical because of lost joint function should the injury not receive appropriate burn care early in the course of recovery.
  21. 21Severity: Burn Injury Location Circumferential burnsencircle a body area such as an arm, leg, or the chest—and especially ones that encircle joint areas—are critical because of the circulatory compromise and nerve damage that result from constriction or from swelling tissues.
    Burns that encircle the chest may impede respiratory function by limiting expansion of the chest.
  22. 22REMEMBER: The 6 critical body areas arethe face, eyes, ears, hands, feet, and genitals.
  23. 23Severity: AgeAge of the patient is also used as a major factor in determining the severity of the burn injury.
    Children under 5 and adults over 55 have less tolerance for burn injuries.
    CHILDREN, in addition to BSA percentage differences, face other challenges:
    -Larger body surface in relation to mass
    -Fluid and heat loss are greater
    -Higher risk for shock
    -Higher risk for airway problems
    -Interference with growth process
    -Possibility of abuse
    Older adults have prolonged healing processes and may have underlying medical conditions that may affect their response to burn injuries.
  24. 24Severity: Pre-existing Medical ConditionsAny pre-existing illness or injury may increase the severity of a burn injury.
    A patient with an existing respiratory illness or condition may be adversely affected if there is further respiratory compromise from a burn injury.
    A patient with an existing cardiovascular problem may have increased complications from a burn injury and resulting fluid loss.
    Diabetes will significantly compromise the patient's ability to heal from the burns.
    You must always realize that what may seem like a minor burn in an otherwise healthy adult may be more severe in those patients with preexisting medical conditions.
    If the patient has experienced other injuries along with a burn injury, the life threat or potential for shock (hypoperfusion) may be increased, as well.
    Remember:
    -Any full thickness > 10% BSA and any partial thickness > 25% BSA
    -Burns to the 6 critical body areas
    -Circumferential burns
    -Burns complicated by airway injury or extremity fractures
    -Remember to upgrade your classification for children under 5 and older adults over 50-55
  25. 25Determining Body Surface Area Burned There are two standard approaches to determining BSA What are they?Rule of Nines
    &
    Rule of Palms
  26. 26Rule of ninesThe rule of nines is a standardized way to quickly determine the amount of skin surface, or the body surface area (BSA) percentage, of a burn. The rule of nines is only applied to burns that are partial thickness or full thickness in depth; it is NOT applied to superficial burns. The calculation is slightly different for adults than infant
  27. 27Rule of Nines An AdultIn an adult the head and neck together, each upper extremity, the chest, the abdomen, the upper back, the lower back, the anterior of each lower extremity, and the posterior of each lower extremity each represents a BSA of 9 percent.
    The genital region represents a 1 percent BSA.    Rule of Nines An Adult
  28. 28Rule of Nines InfantIn infants up to 1 year, there are different BSA percentages assigned to body regions because of their different proportional dimensions.
    The infant's head is much larger in relationship to the rest of the body than in adults. Therefore, for infants one year of age or less, the head and neck are counted as 18 percent, the chest and abdomen as 18 percent (which is the same as an adult), the entire back as 18 percent (same as the adult), each upper extremity as 9 percent (same as the adult), and each lower extremity as 14 percent.
    The rule of nines is altered to allow the head to account for more of the total BSA.    Rule of Nines Infant
  29. 29Rule of PalmsAn alternative way to determine the BSA estimate is to compare it to the PATIENT'S palm (of the hand) surface area, which equals approximately 1 percent of BSA.
    For example, if the burn area is equal to "7 palm surface areas," then the burn would be estimated at 7 percent BSA. You can use this method to estimate a burn area on ANY AGE patient.
    This method is best for small burns, irregularly shaped burns, and scattered burns.
    Do not spend time trying to determine the exact percentage of BSA injured. The BSA percentage is an estimate only.
  30. 30Causes of Burns Burns may be caused by a variety of mechanisms. They include: Flame burn—The patient comes into contact with an open flame. The clothing may ignite, causing further burn injury.
  31. 31Causes of Burns Burns may be caused by a variety of mechanisms. They include: Contact burn—A burn occurs from contact with a hot object. The burn is normally localized to the area of contact.
    An example would be touching a hot exhaust pipe on a car.
  32. 32Causes of Burns Burns may be caused by a variety of mechanisms. They include: Scald—Contact with hot liquid causes a scald burn.
    The more viscous the liquid, the more severe the burn because of a longer contact time.
    Intentional scalds, often seen in child abuse, typically involve the entire extremity from being immersed and held in the hot water.
    Accidental scalds will show patches of burns separated by unburned areas caused by splashing.
  33. 33Causes of Burns Burns may be caused by a variety of mechanisms. They include: Steam burn—Hot steam causes severe burns, often more severe than flame burns, because of the high heat capacity of steam.
    Typically, these types of burns are found in industrial accidents or in those who inappropriately open a car radiator while it is hot.
    Steam can cause thermal burns to the DISTAL airways in the lungs.
  34. 34Causes of Burns Burns may be caused by a variety of mechanisms. They include: Gas burn—Hot gases may cause UPPER airway burns; however, it is not likely that the hot gas will cause distal airway burns.
    Distal airway injury may occur, however, from the byproducts of combustion rather than from the hot gas.
  35. 35Causes of Burns Burns may be caused by a variety of mechanisms. They include: Electrical burn—Because bones, muscles, and other tissues offer resistance to the electrical energy passing through them, the byproduct is heat, which results in INTERNAL burns.
    With an electrical burn, the clothing may ignite, resulting in a flame burn.
  36. 36Causes of Burns Burns may be caused by a variety of mechanisms. They include: Flash burn—This is a type of flame burn but is the result of a flammable gas or liquid that ignites quickly.
    Areas of the body covered by clothing normally are NOT burned.
    Inhalation injury may occur if the flash occurs in a closed space.
    There is a lesser incidence of inhalation injuries when the event occurs outside.
    A typical flash burn would occur from throwing gasoline on smoldering charcoal to reignite it.
  37. 37Assessment of Burn Injuries Scene Size-upYour first priority is to determine whether the scene is safe to enter. Do not enter scenes for which you are not trained.
    If the patient is in an unsafe environment, such as a fire-engulfed building, and you do not have the proper equipment or training to enter, you must wait until properly equipped and trained personnel can safely remove the victim.
    Once the scene is safe to enter, you must take appropriate body substance isolation precautions and then begin assessing the mechanism of injury and number of patients.
  38. 38Assessment of Burn Injuries Primary AssessmentRemember that removing the patient from the burn source does not completely stop the burning process.
    Burn injuries need to be "cooled down" within approximately the first 10 minutes of injury. Stop the burning process initially by using water or saline.
    As you continue working to stop the burning, attempt to remove any smoldering clothing and jewelry which will still be producing heat and may constrict swollen extremities.
    If any clothing still adheres to the patient, cut around the area. Do not attempt to remove the adhered portion, since this may cause further damage to the soft tissues.
    Do not keep the burn immersed, as this may cause hypothermia; cool for 60 to 120 seconds only.
  39. 39Assessment of Burn Injuries Primary AssessmentOnce you have stopped the burning process, you can continue your primary assessment and evaluate the patient's airway, breathing, and mental status.
    Look for any indications that the airway may be injured or compromised, such as, sooty deposits in the mouth or nose, singed facial or nose hairs, signs of smoke inhalation, or any facial burns.
    A burn victim's first reaction when frightened or startled—such as when trapped in a confined space or startled by an explosion—is to deeply inhale.
    Air in these situations may be superheated and will have an adverse effect on the airway and respiratory function. Hence, you need to consider the likelihood of airway compromise and breathing difficulties.
    Provide oxygen by nonrebreather mask at 15 lpm or, if breathing is inadequate, provide positive pressure ventilation with supplemental oxygen.
  40. 40Assessment of Burn Injuries Primary AssessmentTo complete the primary assessment, assess the patient's circulation and determine whether the patient is a priority for transport.
    At this point you will need to make a rapid estimate of the severity of the burn,
    Remember not to spend too long estimating the exact BSA percentage of the burn.
    A burn injury patient is a priority for transport if he is unresponsive with no gag reflex or is responsive but not following commands, if he has airway compromise or difficulty breathing, if he shows signs of shock or uncontrolled bleeding, or if he presents with severe pain.
    A patient with a "critical" burn as discussed earlier should also be treated as a priority patient even though they may not present hemodynamically unstable initially.
  41. 41Most burns do not ____ and are not a cause of ___ shock. Therefore, if signs and symptoms of shock are present, look for other sources of blood loss (_____ shock) or possible spinal injury (_____ shock).bleed
    early
    hemorrhagic
    neurogenic
  42. 42Secondary Assessment: Physical Exam, SAMPLE, VitalsAfter treating all life-threatening injuries, conduct the physical exam. If the patient is alert and does not have a significant mechanism of injury, begin with a modified trauma assessment focusing only on the specific areas of injury.
    If the patient has altered mental status and there is evidence of additional injuries, perform a rapid trauma assessment.
    Check for DCAP-BTLS and get a more accurate estimate of BSA percentage than the one you determined during the primary assessment.
    As you examine the patient, continue to remove his clothing and jewelry, but do not attempt to remove debris or any adhered clothing.
    Take and record the patient's baseline vital signs. Obtain a SAMPLE history from the patient or bystanders, if possible.
  43. 43Questions to Ask In addition to your standard SAMPLE questions, ask the following:-How it happened
    -Cause of burn
    -Length of exposure
    -Any explosion or other significant MOI
    Any LOC
    -Time of burn and care received (rinse any home remedies off that people may have used because they promote burning process)
    -If scald injury, how did it happen
  44. 44Assessment of Burn Injuries ReassessmentEn route to the burn center or hospital, perform a complete detailed physical exam if warranted by suspicion of additional injuries and if time and the patient's condition permit. Continuously repeat the primary assessment by monitoring mental status, airway, breathing and circulation.
    Swelling or closure of the airway may be rapid and emergency medical care will need to be quickly accomplished. Always consider advanced life support (ALS) response when dealing with airway complications in burn injuries.
    Monitor vital signs and check interventions every 5 minutes for unstable patients and every 15 minutes for stable patients.
    Intubate early rather than later!
    -Burns > 20% in adults and >15% in children have systemic capillary leaks (need fluids!!!) -Elevate burned extremities above the heart to reduce swelling
    -Circumferential burns for full thickness
    burns = consider performing an escharotomy
    -Warm the patient to prevent hypothermia
  45. 45General Care-Move the patient from the source of the burn
    -Stop the burning process with water or saline
    -If source is a semi-solid or liquid, (e.g. tar, grease, oil) cool the burn with water or saline but do not attempt to remove the substance by rubbing the area
    -Brush away dry chemicals before flushing
    -Remove any smoldering clothing
    -Expose the burned site
    -Loosen and/or remove any constrictive items or jewelry on the patient's body
    -Cut around adhered clothing
    -Establish and maintain an airway
    -Determine breathing adequacy and provide supplemental oxygen via the most appropriate delivery device
    -Treat any lost function or critical finding of the circulatory status
    -Classify the severity of the burn, and prepare for immediate transport if found to be critical
  46. 46General careCover the burned area with a DRY sterile dressing or a sterile, particle-free disposable burn sheet, or an approved commercial burn dressing.
    Continual use of a wet or moist dressing may cause HYPOTHERMIA because of the loss of heat regulation in the burned area.
    Some EMS systems may use a moist dressing on a 10 percent BSA or less burn that is partial thickness in depth. Check with local medical direction regarding the use of wet or moist dressings.
    –NEVER apply any ointments, lotions, sprays, or antiseptics
    –NEVER break or drain blisters if present
    -Keep the patient WARM and treat other injuries as needed. Remember the burn injury will impair or destroy the skin's heat regulation function and may also be accompanied by other injuries.
    -Transport the patient to the appropriate facility, depending upon the severity of the burn and local protocol for burn injuries.
  47. 47Dressing Burns on Fingers and ToesRemove all rings and jewelry, which may constrict with swelling after the burn injury.
    Separate all digits with dry sterile dressing material to prevent adhering of burned areas.
    Next, cover/wrap all the digits with dry, sterile dressings
  48. 48Dressing Burns of the EyesDo not attempt to open eyelids if they are burned. Determine if the burn is thermal or chemical.
    If thermal, apply a dry, sterile dressing to BOTH eyes to prevent simultaneous movement of both eyes.
    Chemical burns should be flushed with water for at least 20 minutes while en route to the hospital.
    Flush the eye from the medial to the lateral side to avoid washing the chemical into the opposite eye.
  49. 49Chemical BurnsChemical burns require immediate care, since the longer the chemical is in contact with the skin the greater the potential for injury.
    In many cases, emergency medical care may be started by people at the scene.
    Industrial sites may have special response teams or first responders and equipment available to provide initial emergency medical care.
    However, you should follow these rules when dealing with chemical burn injuries:
    -Protect yourself first. As with other burn emergencies, never enter an unsafe scene. Chemical burns may involve a hazardous material incident which you may not be prepared to handle or that may cause you to become exposed.
    -Wear gloves and eye protection at a minimum. In some cases of a large exposure you may have to wear an impervious (fluid-proof) gown or suit to prevent further contamination from the chemical(s).
  50. 50Chemical Burns Emergency CareDry chemicals, e.g., dry lime, should be brushed off before flushing with water.
    Most chemical burns can be flushed with copious amounts of water.
    Always assure that the chemical is one that may be diluted with water. (Consult a hazardous materials guidebook.) There are some chemicals that may produce combustion when they come into contact with water.
    When flushing the eyes, flush medial to lateral with the head rolled to one side to avoid the flush water from entering the opposite eye.
    Continue to flush for at least 20 minutes while en route to the hospital.
    Remove all clothing and jewelry as in other burn injuries.
  51. 51Electrical BurnsElectrical burns, including those caused by electrical currents and lightning, can cause severe damage not only to soft tissues but to the body as a whole.
    Electrical energy will always seek to flow to the ground, and as the energy enters the body it will seek the path of least resistance to exit the body.
    All tissues between the entrance and exit of the current will potentially be injured due to the extreme heat created by the resistance of body structures to the electricity.
    Further, since the body, especially the heart, produces its own electrical energy from chemical reactions, electrical injuries can disturb or destroy these functions, causing irregular heartbeat or even cardiac arrest.
    Much of the burning mechanism may occur within the body
    There is also commonly a "contact" and "ground" burn:
    Point of contact (entry)
    Point of contact (exit)
  52. 52Electrical Burns: Emergency CareNever attempt to remove a patient from an electrical source unless specially trained and equipped
    Never touch a patient still in contact with the electrical source
    Administer oxygen by NRB or provide PPV
    Monitor the patient for cardiac arrest.
    Administer CPR and apply an AED if victim is in cardiac arrest.
    Assess the patient for muscle tenderness with or without twitching and any seizure activity.
    Always assess for entrance and exit burn injury. All tissue in between is suspect for serious injury even if not externally visible.
    Care for external entrance and exit injuries is the same as for other thermal burns.
    Transport expeditiously. Internal tissue or organ damage may have a slow onset and no signs or symptoms will be apparent on scene.
  53. 53Critical Burns Include:Critical Burns Include:
  54. 54Patients with burns are at risk for:–Airway compromise
    –Fluid loss
    –Hypothermia
    –Infection
  55. 55The Rule of Nines is only used to assess body surface area burned for for which of the following types of burns?partial thickness and full thickness burns

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EMT B ACERIP
Created by
Marissa Alvarez · Oct 2017
Updated
Apr 6, 2018
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