INITIAL CARE AND TREATMENT OF BURN INJURIES. November 10,

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2 INITIAL CARE AND TREATMENT OF BURN INJURIES 2 11/10/2012 November 10,

3 Oregon Burn Center Only burn center in Oregon and SW Washington New unit 16 beds, 20,000 square feet Opened in February 2002 OBC offers on site therapy, pharmacy and family centered care November 10,

4 4 Oregon Burn Center State Education and Prevention Program Sponsored by: 11/10/2012 November 10,

5 Objectives Evaluate a burn injury Define magnitude and seriousness of injury Identify and establish priorities of treatment Identify airway injuries Discuss optimal fluid resuscitation Determine patients that should be transferred to a burn center 11/10/2012 5

6 Safety at Home 1.5 million people are burned each year Of these 650,000 are cared for by medical professionals Of these 75,000 will be hospitalized The vast majority of these injuries, >80 % will occur in our own home November 10,

7 Hand on stove-18 months Grease from deep fat fryer - 4 years old Partial thickness / second 11/10/2012 7

8 16 year old driving without seatbelt 11/10/2012 8

9 6 year old playing with matches 11/10/2012 9

10 Hot chocolate 11/10/

11 11/10/

12 Tap water 11/10/

13 Priming carburetor with gasoline Gas on trash fire 11/10/

14 Anatomy of the Skin (The Body s Largest Organ) Epidermis Dermis Sub Q Tissue and capillary network 11/10/

15 Functions of the Skin Protects against infection Prevents loss of body fluids Regulates body temperature Excretes body wastes Produces vitamin D Serves as a sensory organ Defines who we are as individuals 11/10/

16 Burn Injury Classification Thermal Electrical Chemical Inhalation 11/10/

17 Burn Types - Flame Burn Cooking caught shirt on fire 11/10/

18 Burn Types - Scald Burn tar Hot water from stove top 11/10/

19 Hot asphalt 11/10/

20 11/10/

21 FIRST AID KIT Mineral Oil or Petroleum Jelly 11/10/

22 Burn Types - Scald Burn Initial scald burn 11/10/

23 Burn Types - Scald Burn Scald, post burn eleven days 11/10/

24 BURN INJURIES ARE DECEIVING BURN INJURIES CAN GET WORSE OVER TIME 11/10/

25 Electrical Burn Injuries Electrical injuries are some of the most debilitating burns a body can endure. Actual flame burns. Deep hidden tissue damage. Loss of limb or multiple limbs common. Potential for neurological injury. 11/10/

26 11/10/

27 Arc Injury Current does not pass through the tissue High heat, short duration No contact points No hidden tissue damage Rare cardiac arrythmias Volts- 110, 220,480 (480 most common) 11/10/

28 ARC Clothing on Fire 11/10/

29 Arc Flash Flame Burn 11/10/

30 Current Injury Voltage-> 1000 (usually 7000). Tissue acts as volume conductor. Contact points present. Deep, hidden tissue damage often present. Risk of myoglobinuria/renal failure. Limb loss common-usually multiple limb loss with high voltage. Flame injuries may also be involved. 11/10/

31 First contact or entrance site this arm is eventually amputated just below the shoulder 11/10/

32 WITH ELECTRICAL INJURIES THERE IS ALWAYS A POSSIBILITY OF HIDDEN TISSUE DAMAGE 11/10/

33 Deep Tissue Burn 11/10/

34 Current Injury Low Voltage 11/10/

35 LOW VOLTAGE Point of Grounding 11/10/

36 11/10/2012 Grounding points can vary in size

37 Electrical Injuries Always remember to turn off the electricity then remove the source Cardiac arrythmias are rare- if present they will be seen in the first minutes post injury Can result in cardiac arrest More often respiratory arrest is seen 11/10/

38 You First Do not become a victim Check the scene first Remove source of electricity 11/10/

39 At the Scene Remove the heat/ turn off electricity With electrical injuries there is always the possibility of explosions or a fall from a great height - check for other injuries Victim may often be confused and agitated - will want to move around 11/10/

40 At the Scene Do not need to put anything on the burn (burn gel) If possible obtain an accurate history -What happened -Loss of consciousness? -How many volts in contact with -Did bystanders have to do CPR -Did they fall or was there an explosion 11/10/

41 At the Scene Always consider intubation if necessary or if explosion or injury to face involved Start at least 2 IV sites To start - calculate fluid needs based on burn injuries seen - use parkland formula May need more fluids due to hidden tissue damage 11/10/

42 Get All Electrical Contacts Checked Out By a Physician Potential for hidden damage Possible delayed symptoms 11/10/

43 Hidden Damage 11/10/

44 Electrical Current Injuries Any electrical contact should be immediately considered a candidate for potential neurological injury. Some physical symptoms of neurological damage can be delayed after electrical contact, employees should be monitored for the following abnormal symptoms. 11/10/

45 Tremors Weakness Numbness Delayed Symptoms Ongoing headaches Difficulties with speech Vision impairment or changes (double or triple vision) Problems with balance 11/10/

46 Chemical Burn Caused by Drain Cleaner 11/10/

47 Care and Treatment 11/10/

48 10% RULE 11/10/

49 Initial Assessment Primary and secondary survey Distinguish between partial and full thickness burns Apply the rule of nines 11/10/

50 Primary Survey A- Airway B- Breathing C- Circulation D- Disability E- Exposure 11/10/

51 Airway Assess and reassess frequently the need for ET intubation 11/10/

52 Airway Management 3 types of inhalation injury 1. Carbon monoxide poisoning 2. Inhalation above the glottis 3. Inhalation below the glottis 11/10/

53 Carbon Monoxide Poisoning Most fatalities are due to CO poisoning Signs and symptoms May have cherry red skin only present in 50% of cases O2 sats are normal Cyanosis and tachypnea not usually present Need to determine CO levels in blood for accurate diagnosis 11/10/

54 BEST TREATMENT FOR CO POISONING IS OXYGEN 11/10/

55 Inhalation Above the Glottis Most heat damage occurs above true vocal cords Results in severe edema that may occlude airway Early intubation preferred 11/10/

56 Flame Face Burn 11/10/

57 5 Hours Later 11/10/

58 Injury Below the Glottis Almost always chemical Chemicals adhere to smoke particles and cause direct damage to epithelium of large airways 11/10/

59 Injury Below the Glottis Severity and extent of damage are unpredictable based on history and physical exam Need to continue to reassess on a regular basis 11/10/

60 Initial Management of Inhalation Injury Give 100% O2 at 15L by nonrebreather mask Intubate if indicated by: Progressive hoarseness and stridor Decreased LOC so that airway protective reflexes are impaired 11/10/

61 Other Physical Findings Carbonaceous sputum Facial burns Singed nasal hairs Agitation due to hypoxia Intercostal retractions Hoarseness, stridor Inability to swallow 11/10/

62 Intubation Have most experienced person intubate Secure tube with umbilical tape Regular tape will not stick to burned skin Emergency Cricothyroidotomy is rare 11/10/

63 IF YOU DO NOT HAVE A DEFINITIVE AIRWAY THERE IS NOT A LOT YOU WILL BE ABLE TO DO. EDEMA WILL CONTINUE FOR UP TO 48 HOURS. 11/10/

64 Inhalation in Pediatrics Upper airways small Obstruction occurs rapidly Use careful tube selection size Position properly Secure well to prevent dislodgement 11/10/

65 11/10/

66 Breathing Listen to breath sounds Apply high flow O2 15 L at 100%- non rebreather mask Monitor chest wall in the presence of deep torso burns 11/10/

67 November 10,

68 Circulation Establish IV access 2 sites if possible, through burned skin is OK Monitor blood pressure Assess and monitor frequently circumferentially burned extremities 11/10/

69 Disability Burn injuries should be alert and oriented IF not consider: Associated injuries CO poisoning Substance abuse Hypoxia Pre-existing medical conditions 11/10/

70 Exposure Remove all clothing and jewelry Maintain body temp, keep patient covered 11/10/

71 ONE OF THE BEST THINGS YOU CAN DO IS KEEP YOUR PATIENT WARM Raise Room Temperature Solar Blankets Clean blanket or sheet 11/10/

72 Secondary Survey Head to Toe to note other injuries Most important is circumstances of injury How did it occur? Inside/outside? Gasoline or other fuel involved? Explosion? Is it a scald, flame, electrical or chemical contact? 11/10/

73 Burn Wound Assessment Superficial Partial thickness Full thickness Fourth degree 11/10/

74 Superficial Burn Characteristics Intact skin Red appearance Painful Burn is through epidermis Usually heals in 5-10 days Example: sunburn 11/10/

75 11/10/

76 ORAL REHYDRATION AND OTC PAIN MEDICINES 11/10/

77 Partial Thickness Burn Burn through epidermis and dermis Skin is not necessarily intact Skin is loose Moist, red appearance Blistered Subcutaneous edema may be present 11/10/

78 11/10/

79 LESS THAN 10% - ORAL REHYDRATION AND OTC PAIN MEDS. ANTIBIOTIC CREAM, KEEP WOUND COVERED. 11/10/

80 Full Thickness Burn Burned through epidermis, dermis, and subcutaneous tissue Dry appearance May be red, white, black, or brown in color Leathery in appearance 11/10/

81 11/10/

82 LESS THAN 10% - ORAL REHYDRATION AND OTC PAIN MEDS. ANTIBIOTIC CREAM, KEEP WOUND COVERED. 11/10/

83 Fourth Degree Burn Burned through epidermis, dermis, subcutaneous tissue, muscle, and bone Charred appearance May appear cracked Immobility of area 11/10/

84 Car fire 11/10/

85 KEEP COVERED AND PROTECTED NEEDS AMPUTATION 11/10/

86 Assessment of Extent of Injury The rule of nines -. >Used for both adults and peds. The rule of palm. >The surface area of the patients hand is = to 1%of their total body surface area. 11/10/

87 11/10/

88 Infant- Modified Rule of Nines 10% 10 16% % Front 16% back 14 % 14% 11/10/

89 Fluid Resuscitation Proper fluid management is critical to survival Objectives are to: -Maintain tissue perfusion and organ function -And to avoid complications of inadequate or excessive fluid therapy 11/10/

90 Excessive Fluid Resuscitation Edema is usually at its max hours post burn Too much fluid will exaggerate edema formation Compromise local blood supply 11/10/

91 Excessive Fluids Patients sensitive to excess fluids are Elderly Children And pre-existing cardiac disease 11/10/

92 Inadequate Resuscitation Results in shock and acute renal failure May have multiple organ dysfunction 11/10/

93 Fluid Resuscitation Establish large bore IV sites 2 if possible Go through burned skin if necessary Interosseous route ok for children 11/10/

94 Fluid Resuscitation Use LR if possible In adults and older children: 2-4 ml x wt in kg x %TBSA In children: 3-4 ml x wt in kg x % TBSA Plus D5LR at a maintenance rate 11/10/

95 Fluid Infuse ½ of estimated volume in first 8 hours and rest over next 16 hours Remember that this is a starting point and must be adjusted to patients needs according to urinary output 11/10/

96 Hourly Urinary Output Adults: cc per hour Children less than 30 kg: 1cc/ kg/ hour 11/10/

97 Changes in Fluids If output is greater or less than recommended increase or decrease fluid by 1/3 11/10/

98 HYDRATION ENEMAS AND OTHER FUN WAYS TO GIVE FLUID! 11/10/

99 Circulation Management Check to see if burn is circumferential in nature -Monitor distal pulses -Escharotomy may be indicated for long transports 11/10/

100 Escharotomy Rarely indicated prior to transfer May be required to permit adequate ventilation in chest burns May be required to maintain tissue perfusion in extremity burns Please consult with burn center before performing escharotomy 11/10/

101 Signs and Symptoms Cyanosis of distal, unburned skin Unrelenting deep tissue pain Progressive numbness Progressive decrease or absence of pulses 11/10/

102 Escharotomy Can reduce chances of escharotomy by elevating area and encouraging ROM 11/10/

103 4 Hours Post Burn 11/10/

104 ESHCAROTOMIES CAN OFTEN WAIT UP TO 8 HOURS - ELEVATE THE AFFECTED AREAS - ENCOURAGE RANGE OF MOTION 11/10/

105 Other Factors to Consider Pre- existing conditions Medications, alcohol, drug use Allergies Tetanus history Last food or drink 11/10/

106 Review of Management Principles Stop the burning process Monitor vital signs frequently Insert Foley* Begin fluid resuscitation Assess extremity perfusion Monitor ventilation frequently Stay on top of pain management Emotional assessment of the patient 11/10/

107 Management of Major Burns Cont: Monitor for Urine Myoglobinuria Monitor Body Temperature Prevent unnecessary contamination of injury Pain Medication as appropriate IV is the only acceptable route 11/10/

108 ABA Transfer Criteria 2 nd degree burns > 10 % Burns to hands, face, feet, genitals, major joints 3 rd degree burns Electrical burns Chemical burns Inhalation injuries Burns with pre-existing medical condition Burns accompanied by trauma where the burn is the greater risk to life Burns to children in hospitals without pediatric services Patients with special social, emotional or rehabilitative needs 11/10/

109 Wound Care 11/10/

110 Prepare Supplies Ahead of Time Set everything up where you can reach it. Open gauze ahead of time. Pull your tape, have scissors ready. Ready a basin of warm soap and water (mild soap, like baby soap)

111 Clean the Wound Do not scrub hard, but try to remove soot, ashes and other dirt as much as possible. Do not worry if you cannot remove all the dirt, it will come off with additional dressing changes. If you are redressing a wound, completely wash away the old silvadene.

112 Keep Patient Warm Increase the room temperature prior to admitting patients or doing dressing changes. Burn patients can become hypothermic quickly when exposed. Dress one limb at a time, keeping the rest of the body covered with warm blankets.

113 If You Have Limited Supplies If you do not have Silvadene Use double antibiotic ointment Goal is to keep the wound moist If you have do not have antibiotic ointment Use petroleum jelly If you have do not have burn pad or gauze Smear on Silvadene or other topical, wrap the patient in a sheet.

114 Wrapping Hands 11/10/

115 Silvadene Smeared on Hand November 10,

116 Hold gauze with the bulk of the roll in the dominant hand, the first layer pulled from under the roll. This makes it easier to unroll and wrap the extremities. November 10,

117 To start: anchor once around wrist November 10,

118 Wrap fingers individually, loop back and forth across dorsum and palm, catching each finger as you go. November 10,

119 Come up across dorsum of hand, then go around and under, across the palm. November 10,

120 Wrapping Heads and Faces 11/10/

121 Make a Vest 11/10/

122 A SUPPLY LIST: Trauma Shears Tylenol Tape Rolls of Gauze Mineral oil Double antibiotic cream Petroleum jelly Blankets Solar blankets Water for washing wounds* Gentle soap Sheets, Pillow Cases Matches Scalpel *Water must be clean 11/10/

123 OTHER ITEMS YOU MAY BE ABLE TO USE: Pillows Tight t- shirts to hold dressings in place Do households around you have any pain medications? Children s dissolvable Tylenol Cotton blankets to assist in moving a patient Garbage bags Burn Gel* 11/10/

124 Summary Burns constitute a major cause of morbidity in traumatized patients. Principles of initial resuscitation include: >Aggressive Airway Management >Breathing >Circulation Management Burn Wound Assessment needs to be done in the secondary survey. 11/10/

125 Thank you!