Chapter 19 Burns

Objectives 19.1 List four types of burns. 19.2 List the signs and symptoms for each type of burn. 19.3 Compare and contrast the methods for classifying burns. 19.4 Describe the clinical significance of a voice change in the setting of a thermal burn. continued

Objectives 19.5 Compare and contrast direct current and alternating current. 19.6 Describe how to assess burn severity using the “Rule of Nines” system. 19.7 Describe and demonstrate the management of a burn patient.

Topics Anatomy and Physiology Burn Sources Burn Classifications Assessment Management Chapter Summary

Case Presentation A 4-year-old boy has pulled a boiling hot dish out of a microwave and onto himself. The mother is with him and is crying vigorously. He has no past medical history, is taking no medications, and has no allergies. Discussion Point: What should you do?

Anatomy and Physiology Skin Largest organ of the body Two layer Multipurpose Vulnerable to damage when exposed to extreme temperature, caustic substances, and other hazardous sources Discussion Points: What are some of the important functions? Protection of underlying structures—organs Protection from invading pathogens Temperature regulation, prevention of fluid loss Synthesis of vitamin D

Anatomy and Physiology The anatomy of the skin.

Burn Sources Thermal Chemical Electrical Heat comes directly into contact with skin Chemical Exposure to a caustic substance Electrical Contact with an electrical current Discussion Points: Thermal burns need temps greater that 46 C of 115 F. Common causes open flames, hot water or steam or superheated air Chemical burns can occur with either acid or bases; depending on the pH of the substance. Strong acid has pH of 1, strong base has pH of 14. Electrical burns: AC (alternating current) is more dangerous than DC (direct current) continued

Burn Sources Radiation Exposure to a radiation emitting object UV Light exposure Discussion Points: Exposure can be either brief as in exposure to radiation (X-rays). 3 types of natural radiation: alpha, beta and gamma radiation. Gamma is the most dangerous and penetrates the skin the deepest. Another source of radiation burn is from UV light. Be careful at higher altitudes with the less-dense atmosphere.

Burn Classifications Determined by depth of skin damage Thickness-based Superficial Partial thickness Full thickness Degree-based First Second Third Fourth Discussion Points: Both thickness-based and degree-based terminology is used emergency and burn medicine. Superficial burn (first degree) mildest form Partial thickness (second degree) affects both epidermis and dermis Full thickness (third degree) is devastating that affects all layers of skin and can extend into underlying structures Fourth degree burn the skin is blackened and includes muscle and bone.

Burn Classifications Copyright Charles Stewart M.D. and Associates Copyright Edward Dickinson, M.D. • A partial-thickness burn; note redness and blisters. • A full-thickness burn. • This full-thickness burn is an electrical burn.

Case Update After confirming that the ABCDs are intact, you call for assistance and begin a secondary assessment. You note that the boy’s chin and the front of his neck for a distance of about twice as long as his palms are bright red and are surrounded by larger areas of redness in a splash-like pattern. Blisters are forming on his chest. He is breathing rapidly and his heart rate is 110 and regular at the brachial artery pulse point. Discussion Points: What is the first thing the patroller does for the burn patient? How does the patroller determine the severity of the injury? What other information should the patroller be documenting?

Assessment Scene safety is a first priority Use BSI and PPE Airway/breathing is a major concern Collect information on the burning agent Determine severity with degree or thickness based method Discussion Points: Always look for changes indicating inhalation injury which could compromise airway including: obvious burns to face, head or neck; singed hair or eyebrows; soot around mouth/nostrils; hoarseness/voice changes; airway swelling continued

Assessment Use the Rule of Nines to determine extent of partial/full thickness burns Check for critical issues Treatment should be at a burn center if possible Discussion Points: Where is the nearest burn center to your area?

Assessment The Rule of Nines for estimating the proportion of the body surface affected by burns.

Assessment The criteria for designating burns as critical.

Management Safety concerns take priority Stop the burning process Care for ABCDs CPR may be needed for electrical burn patients Control bleeding Remove clothing and jewelry Cool and irrigate with room temp water Discussion Points: Remember that safety of the rescuer is of top importance. DO NOT go into a situation where you could be burned as well! continued

Management continued • Emergency supplies needed to care for burns. • The first goal of initial burn care is to stop the burning process. • Extinguish any burning or smoldering clothes before removing them. continued

Management Cover with clean linens/blanket After cooling use dry, sterile dressings Smaller burns may use clean, wet, cool dressings Do NOT apply creams, ointments, etc. Treat for shock continued

Management Extensive Burns Remember that with extensive burns, patients lose the ability to thermoregulate. Make sure they do not become hypothermic by wrapping them in warm, dry sheets. continued

Management Elevate upper body if burned to minimize edema Transport all but most minor burns to a burn or trauma center if possible Use a clean, dry sheet to prevent the patient from sticking to the transport device. Discussion Points: What are some of the transport considerations if the entire body is burned?

Thermal Burns Put out the flames – “Stop, Drop and Roll” or smother Do not use chemical fire extinguishers Remove burned, singed, or smoldering clothing, or clothing soaked in hot liquid Do not pull if fabric has melted onto skin Do not break blisters Do not apply cold compresses Discussion Points: Be sure to remove jewelry near the affected area.

Chemical Burns Use PPE to avoid contamination Remove all clothing and jewelry Consider Hazmat Brush off dry chemicals Irrigate with large amounts of tepid water (15 mins, or until burning ceases) Do not try to neutralize Chemtrec #: 800.262.8200 Discussion Points: Neutralizing a chemical burn may cause a thermal reaction worsening the injury.

Chemical Burns Chemical Burn Alert Caution! When managing chemical burns, do not apply a neutralizing agent because this may cause a thermal reaction, worsening the injury. Dust off any dry chemicals and irrigate the area with room-temperature water. Note as well that the application of water to some chemicals also produces heat. • Flush chemical substances from the eyes. • After flushing, apply sterile gauze pads to both eyes.

Electrical Burns Make sure the power is OFF Immobilize on a backboard Maintain airway, give oxygen Do CPR (use AED) if necessary Check for entrance/exit wounds Discussion Points: Remember that patients injured by electricity are worse off than they present. Many of the injuries are beneath the surface. Very important to take vitals frequently.

Electrical Burns Entrance and Exit Wounds Remember that patients injured by electricity often appear to be much better off than they actually are because many of their burns are beneath the surface. Take vital signs frequently and be prepared for extensive resuscitation (CPR and AED). Electricity passing through an individual may cause a variety of injuries in addition to entrance and exit burns.

Radiation Burns If the burn is not from ultraviolet light, the patient should be treated only by HAZMAT personnel. UV burns (sunburn) are usually treated as first-degree burns. Discussion Points: DO NOT enter an area where patient has been contaminated by radioactive material—need special protective gear

Case Disposition What are the patroller’s findings? What treatment and transportation choices were made?

Chapter Summary Rescuer and bystander safety is the top priority when treating a burn patient. The four types of burns are thermal burns, chemical burns, electrical burns, and radiation burns. The focus of treatment is stopping the burning process. Discussion Points: What kinds of burns might we encounter? What should be the first priority in burn situations? How do we assess burns? What are common steps in treating burns? What are some of the specific treatments for specific burns? continued

Chapter Summary Brush off dry or powdered chemicals first. Irrigate chemical burns with water for a minimum of 15 minutes. Inhalation injuries are often associated with facial burns and vocal hoarseness. Always be aware of any changes that would indicate a compromised airway continued

Chapter Summary Burns are classified by the depth of the injury. Use the Rule of Nines to calculate the extent of burns. Do not delay transport of patients with significant burns. Treat burn patients for shock and hypothermia. continued

Chapter Summary Transport burn patients to a burn center or trauma center, whenever possible.