1. Emergency Evaluation and Treatment of Burns Sarah Seiler, RN, BSN, NREMT-P CCRN, CEN Emergency Medicine Outreach Coordinator

2. Statistics 1.25 million burn injuries per year 4,550 fire and burn deaths per year 3,750 deaths from house fires Fire and burn deaths have declined by 50% since 1971 45,000 hospitalizations per year 600,000 annual emergency department visits per year The Burn Foundation http://www.burnfoundation.org

3. Burn survival graphBurn survival graph

4. Functions of the Skin Protection –Prevents invasion of environmental toxins and microorganisms Immunologic –Sebum has antibacterial properties which helps shed topical bacteria Thermoregulation –Insulates from heat loss and controls loss of heat through evaporation

5. Functions of the Skin cont’d Fluid and Electrolyte Balance –Controls sodium excretion –Sebum retards fluid loss from skin Metabolism –Produces Vitamin D –Prevents excessive fluid loss Neurosensory –Nerve endings and receptors process environmental stimuli for pain, touch, heat and cold Social and Interactive –Provides body image and personal identity Carrougher Burn Care and Therapy

6. Anatomy and Physiology of the Skin

7. A and P of the Skin cont’d Epidermis First layer of defense Composed of dead, keratinized cells and surrounded by a lipid monolayer There are no blood vessels. It is fed by capillaries in the dermis. If the epidermis is destroyed but the appendages of the dermis remain, a new epidermis is formed when the epithelial climb up the hair follicles.

8. A and P of the Skin cont’d Dermis Collagen and fibrous connective tissue Contains capillaries and arterioles Has special sensory nerve fibers and lymph system –Meissner Corpuscle: light touch, just beneath epidermis –Vater Pacini Corpuscles: pressure sensors, deep in subq –Ruffini Corpuscles: heat sensors, deep in subq tissue –Krause Corpuscles: cold sensors, deep in subq tissue

9. A and P of the Skin cont’d Subcutaneous Tissue Connective tissue Fat cells in most areas Blood vessels Nerves Base of hair follicles Function: Insulation Storage of nutrients

10. Types of Burns Superficial Superficial partial thickness Deep partial thickness Full thickness

11. Superficial Burn Sunburn Involves only the epidermis Local pain and erythema No blister formation Heals spontaneously without scarring Systemic response is minimal

12. Superficial Burn

13. Partial Thickness Burn Can be superficial or deep Involves epidermis and dermis Has blister formation Moist appearance Tactile and pain sensors intact Will usually heal on own but will scar

14. Partial Thickness

16. Full Thickness Burn Involves all layer of skin Has waxy and dry appearance Elasticity destroyed Painless Does not heal without intervention

17. Full Thickness

19. Determining Burn Severity Depth of the burn Superficial Partial thickness Full thickness Body surface area

20. Estimating BSA Rule of Nines Easiest to use, best for field use Lund Brower More accurate, used in hospital Palmar Estimates scattered burns Patient’s palm is 1% of his/her BSA

21. Rule of Nines

22. Rule of Nines for Children

23. Lund Brower

24. Initial Treatment STOP the burning process AIRWAY, AIRWAY, AIRWAY High flow humidified O2 Remove all clothing – keep warm Decontaminate chemical burns Pain control –Do not give SQ or IM

27. Signs and Symptoms of Airway Injury Soot around the nose and mouth Singed nasal hairs Complains of shortness of breath Wheezing or rales on auscultation

28. Signs and Symptoms of Airway Injury cont’d Agitation, tachypnea, anxiety, stupor, cyanosis Disorientation, obtundation, coma Hoarse voice, brassy cough

29. Signs and Symptoms of Airway Injury cont’d Rapid respiratory rate, flaring nostrils, intercostal retractions Stridor Sooty sputum History of the event

30. Airway Protection

31. Edema with Fluid Resuscitation

33. Inhalation Injury Prognosis  risk of nosocomial infection  length of stay  cost of hospital care  mortality by up to 20%

34. Carbon Monoxide Poisoning Hemoglobin has 200-250 times greater affinity for CO than oxygen Most on-scene fatalities are caused by asphyxiation and/or carbon monoxide poisoning. Normally present with normal PaO2 Usually normal color and no respiratory distress Suspect based on history Until recently definitive diagnosis could only be made by measuring carboxyhemoglobin levels in blood

35. MASIMO

36. Signs and Symptoms of Carbon Monoxide Toxicity Carboxyhemoglobin Saturation 5-10% 11-20% 21-30% 31-40% 41-50% >50% Signs and Symptoms Impaired visual acuity Flushing, headache Nausea, impaired dexterity Vomiting, dizziness, syncope Tachypnea, Tachycardia Coma, death

37. Treatment of CO Poisoning High Flow O2 !!!!!!!!!

38. Fluid Resuscitation If <60min from facility, IV not necessary Parkland Formula –2-3ml/kg/%BSAB –half given over the first 8hr since burn injury and half over the second 16 Maintain a urine output of 30-50cc/hr

39. Adequate Resuscitation BP not accurate – edema makes BP difficult Pulse may be more helpful –Maintain close to normal range Urine output is most accurate in adult –Maintain between 30-50cc/h

41. Resuscitation Made Easy If burn (2° or 3° ) greater than 15% of total body surface (or if there are other injuries) Infuse lactated Ringers (Estimate of Requirements): –15-25% TBS = 500 ml per hour –25-50% TBS = 750 ml per hour –> 50% TBS = 1 Liter per hour

43. The Burn Injury Results In Decreased cardiac output Increased heart rate Decreased tissue perfusion Stasis of blood Tissue ischemia Anaerobic metabolism Metabolic acidosis

44. Fluid and Protein Loss

45. Special Considerations for Resuscitation Elderly Pediatric Electrical burns Pre-existing cardiopulmonary conditions

46. Circumferencial Burns of the Chest

48. Escharotomy

49. Pediatric Statistics Second leading cause of death 250,000 children each year 15,000 are hospitalized 1,100 deaths from fire and burn injuries The Burn Foundation http://www.burnfoundation.org

50. Pediatric Statistics 100,000 are burned from scalds from spilled food and beverages 18,700 are burned by curling and clothing irons 3,200 burned by fireworks 1,500 burned by gasoline and matches 1,500 burned by cigarettes The Burn Foundation http://www.burnfoundation.org

51. Pediatrics Reliable indicators of adequate resuscitation –Mental clarity –Pulse pressures –Arterial blood gases –Distal extremity color –Capillary refill –Body temperature

52. Pediatric Abuse

53. Electrical Burns

55. Electrical Burn to the Hand

56. This is the Same Hand!!!!

57. Treatment for Electrical Burns Scene Safety –Remove from source after disconnecting ABCs 12 lead EKG –Nonspecific ST changes and A fib most common IV –Usually require more fluid Labs –CK-MB to check for muscle damage

58. Long Term Treatment Early exploration of wound (within 24h) Debridement Fasciotomy Amputation

59. Increased Risk of Cardiac Damage Loss of consciousness Documented cardiac arrhythmia Abnormal EKG Chest pain and palpitations

60. Complications Renal failure Pulmonary Edema Infection Acidosis Cardiac dyrhythmias Cardiac arrest Myocardial injury Amputation

61. Urine Myoglobin What is it? –Large protein released from damaged renal tubules. –Can occlude renal tubules and cause renal failure. –Usually in very large, deep or electrical burns.

62. Treatment for Myoglobinuria Increase IVF to maintain UO at 75-100cc/h Administer NaHCO3 to buffer the kidney

63. Chemical Burns Can be liquid, solid, or gas Usually deeper than it looks Appearance is brown to gray If have severe persistent pain, it is still burning. Some can lead to systemic poisoning (i.e. phenol and gasoline)

64. Treatment for Chemical Burns ABCs Remove clothing and constrictive objects (jewelry) Obtain a good history –Place, nature, and duration of exposure –What are the chemicals –Specific toxic properties –Relevant patient history –Current symptoms

65. Chemical Wound Management Brush off chemicals first Continuously irrigate for 20-30min minimum Do NOT attempt to neutralize acids or alkalis. Notify ED PTA if unable to decontaminate

66. Sulfuric Acid Lime Burn

67. Asphalt Tar

68. Methamphetamine Labs In 2002, more than 7,500 labs seized in 44 states. Can be located anywhere from apartment to trailer to house to car to motel Signs of Lab Unusual odors Excessive amounts of trash, especially chemical containers Curtains drawn or covered with aluminum foil Extensive security measures Frequent visitors at unusual times

69. Methamphetamine Lab Risks May ignite or explode easily Chemical burns SOB, cough, chest pain Possible Ingredients –Pseudoephedrine –Acetone/ethyl alcohol –Freon –Anhydrous ammonia –Red phosphorus –Lithium metal –Hydriodic acid –Iodine crystals –phenylprpanolamine

70. Methamphetamine Labs Common Equipment –Aluminum foil –Blenders –Cheesecloth –Clamps –Coffee filters –Jugs and bottles –Lab beakers –Measuring cups –Propane cylinders –Rubber gloves –Strainers –thermometer Common Products –Acetone –Alcohol (isopropyl or rubbing) –Pseudoephedrine –Ether (engine starter) –Hydrochloric acid (pool supply) –Iodine –Kitty litter –Salt –Lye –Sulfuric acid (drain cleaner) –Toluene (brake cleaner) –Trichloroethane (gun cleaner)

71. Methamphetamine Behavior Psychiatric symptoms  aggressiveness Arrhythmias MI Cerebral hemorrhage Anorexia With withdrawal –↓ psycomotor performance –Accumulated sleep debt

72. Methamphetamine Burns More likely to have inhalation injury Greater extent of full thickness burns Increased risk of nosocomial pneumonia and respiratory failure Increased risk of sepsis Longer hospital and ICU stays Higher mortality

73. Cyanide In 1998, 350 documented cyanide deaths Hydrogen cyanide in wool, silk, polyurethane (furniture cushion), urea formaldehyde, melanine (dishwasher), acetonitrile (artificial fingernail remover) Common in metal trades, mining, electroplating, jewelry manufacturing, xray films Cassava (potato), apricot pits

74. Cyanide Poisoning More difficult to diagnose than CO poisoning Common with smoke inhalation from residential and industrial fires. Used in suicide Suspect in patients with an unexplained metabolic acidosis and elevated lactic acid levels because shifts cellular metabolism from aerobic to anaerobic Individuals who survive have increased risk for CNS dysfunction

75. Cyanide Poisoning Signs and Symptoms May be delayed depending on type, route, and dose Headache, vertigo, dizziness, giddiness, inebriation, confusion Seizures Coma Shortness of breath, tachypnea, apnea Abd pain, nausea, vomiting General weakness, malaise

76. Cyanide Poisoning Signs and Symptoms Initial bradycardia and hypertension may quickly change to hypotension Pulse oximetry inaccurate Cherry red skin color (rare and late) Smell of bitter almonds on breath (60% of population) Soot in mouth and nose if smoke inhalation

77. Cyanide Poisoning Treatment Scene safety/Decontaminate Airway protection EKG –May show AV blocks, SVT, Ischemia, Asystole Sodium Bicarb if unconscious or hemodynamically unstable and acidotic Cyanide antidote kit =amyl nitrite, sodium nitrite, and sodium thiosulfate –Don’t use sodium nitrite in smoke inhalation because ↓ carrying capacity if blood

78. Cyanide Poisoning Treatment Arterial and venous blood gas –Metabolic acidosis and ↓ oxygen Lactic acid levels –>10mmol suggest cyanide Carboxyhemoglobin Plasma cyanide concentration Methomoglobin –For monitoring nitrite therapy

79. Special Concerns in Pregnancy with Cyanide Fetal demise is possible Aggressive support and antidotal treatment of mother is imperative Obstetric evaluation after stabilization Therapeutic abortion may be necessary in fetal demise

80. Burn Center Referral Criteria Partial thickness burns > 10% TBSA Burns that involve the face, hands, feet, genitalia, perineum, or major joints Third degree burns in any age group Electrical burns, including lightening injury Inhalation injury

81. Burn Center Referral Criteria cont’d Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality. Any burn injury with concomitant trauma in which the burn injury poses the greatest risk of morbidity or mortality. Burned children of any degree should be transferred to a facility equipped to care for them. Burn injury in patients who will require special social, emotional, or long-term rehabilitation American Burn Association

82. Transportation

83. American Burn Association www.ameriburn.orgwww.ameriburn.org Arnoldo, B. et al. Practice guidelines for the management of electrical burns. Journal of Burn Care and Research. 2006;27:439-447. www.burnsurgery.org Carrougher, G. Burn Care and Therapy. Mosby;1998. Sai, N. et al. The comparison of early fluid therapy in extensive flame burns between inhalation and noninhalation. Burns. 1998;24:671-5. Herndon, D. Total Burn Care 2 nd Edition. Elsevier Science;2001. Leybell, I. et al. Cyanide Toxicity. Emedicine. 2006. http://www.emedicine.com/emerg/topic/topic118.htm http://www.emedicine.com/emerg/topic/topic118.htm National Drug Intelligence Center, U.S. Department of Justice. Methamphetamine Laboratory Identification and Hazards. http://www.usdoj.gov/ndic Spann, M, et al. Characteristics of burn patients injured in methamphetamine laboratory explosions. Journal of Burn Care and Research. 2006;27:496-501. Tomaszewski, M.D. C. Carbon monoxide poisoning: early awareness can save lives. Postgraduate Medicine. 1999; 105 References