PreHospital Burn Management Part 1: The Basics

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Pre-Hospital Burn Management Part 1 The Basics

• Robert S. Cole
• Paramedic, CCEMT-P

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For this class I referenced text from

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Advanced Burn Care in the Field

• It is difficult to go over the aspects of burn
  care in a mere hour, ABLS takes 16 hours for its
  burn course. For a more detailed and in complete
  look, taking the ABLS class is highly
  recommended. This lecture will try to hit on
  some hopefully new and exciting material to Take
  home with you while still doing justice to the
  basics..

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Objectives

• Understand the basic anatomy and function of the
  skin
• Identify the types of common burn trauma
• Accurately assess the burn severity, and common
  progression of patient condition
• Identify co morbid factors

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The Basics

• A Review

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The Skin

• Largest Organ in the human Body
• Sensory
• Temperature Regulation
• Barrier vs. Infection and Fluid loss
• Identification and form

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The Skin

• Three Basic Layers
• The Epidermis 3 sublayers. The stratum corneum
  , the squamous layer , and the basal layer ,
  these are the outer layers, providing protection
  and pigment.
• The Dermis The Layer that contains blood
  vessels, lymph vessels, Hair follicles, and sweat
  glands, all held together by COLLIGEN.
• The subcutaneous layer, AKA the subcutis, forms a
  network of collagen and fat cells. The subcutis
  is responsible for conserving the body's heat,
  while helping to protect the organs of the body
  from injury by acting as a "shock-absorber".

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The Skin
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Types of burns

• Thermal (Flame, Steam, scalds, sunburn, etc.)
• Chemical (Lye, Hydrofluoric Acid)
• Electrical
• Radiological

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Assessing the Burns

• Primary Goal is to assist with the rapid
  evaluation of severity of the burns and to
  facilitate transfer to a burn center if needed.
• Secondary goal is to give all providers a common
  ground and language when discussing these burns.
• Rule of 9s, ABA Criteria

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Assessing the Burns

• Most field providers and non burn specialist
  often UNDERESTIMATE BSA of burn.
• In reality even after the primary burning process
  stops, heat retention in the body continues to
  damage the tissue. True extent of burns may not
  be evident for several hours.
• It is more important to get an initial working
  idea on SEVERITY of the Pt as a whole, not just
  focusing on BSA, Consider ALL factors.

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Assessing the Burns

• The Rule of 9s for BSA (Simi Complex, Simi
  Accurate, widely used)
• Lund and Browder method (complex, accurate)
• ABA classification for severity (Considers whole
  picture)
• The traditional classification of burns as first,
  second or third degree is being replaced by the
  designations of superficial , superficial partial
  thickness , deep partial thickness and full
  thickness .

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The Rule of 9s
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ABA Grading System Minor Burns

• lt10 percent TBSA burn in adult
• 5 percent TBSA burn in young or old
• lt2 percent full-thickness burn

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ABA Grading System Moderate Burns

• 10 to 20 percent TBSA burn in adult
• 5 to 10 percent TBSA burn in young or old
• 2 to 5 percent full-thickness burn
• High-voltage injury, suspected inhalation
  injury,circumferential burn
• Concomitant medical problem predisposing the
  patient to infection (e.g., diabetes, sickle cell
  disease)
• Minimum Care Hospital admission

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ABA Grading System Major Burns

• gt20 percent TBSA burn in adult
• gt10 percent TBSA burn in young or old
• gt5 percent full-thickness burn
• High-voltage burn Known inhalation injury
• Any significant burn to face, eyes, ears,
  genitalia or joints
• circumferential burn w/ compromise
• Significant associated injuries (e.g. fracture,
  other major trauma)

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Assessing the Burns

• 1st degree or superficial Burn
• Painful,
• Red
• Dry
• Blanch with pressure
• Sunburn, low intensity flash burn
• Pain is the major issue to deal with

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1st degree/superficial
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Assessing the Burns

• Second Degree Burns, AKA Partial Thickness
  (Deep vs. Superficial)
• Typically painful unless nerve endings are
  damaged
• Blisters,
• High Intensity Flash Burns, Hot Grease, Steam and
  Flame
• Infection, swelling, and Pain are primary initial
  concerns.
• Dehydration may develop over time with large BSA.

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2nd Degree, Superficial Partial Thickness
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2nd Degree, Deep Partial Thickness
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Assessing the Burns

• 3rd degree, AKA Full Thickness
• May be white and waxen or may be charred
  (Eschar).
• No sensation is typical,
• Cap refill is absent
• Primary concerns are infection, pain control and
  severe swelling

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Assessing the Burns

• A common Misconception is that 3rd degree Burns
  are painless.
• In reality while 3rd degree burns may be
  insensate the burns are usually surrounded by a
  Halo of severe and very painful 2nd degree burned
  tissue, known as the Zone of Stasis
• This is further complicated by the swelling that
  develops with 2nd and 3rd degree burns causing
  further pain .

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3rd degree , Full thickness
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Assessing the Burns

• 4th Degree or Bone Burns
• Classification occasionally used in some texts
• Used to describe the massive destruction of
  tissue to effected areas
• Often appears To the Bone

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Complicating Factors
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Complicating or Co-Morbid Factors

• Associated Trauma
• Inhalation Injuries
• Circumferential Burns
• Electricity
• Age (Young or Old)
• Pre-Existing Disease
• Abuse

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Associated Trauma

• Spinal Injuries
• Airway Trauma
• Chest Trauma/Baro Trauma
• Abd. Trauma
• CHI
• Open wounds/Fractures/Shrapnel
• Shock
• If you find a Hypotensive acute burn Patient,
  there is something else you are missing!

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Inhalation Injuries

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Inhalation Injuries

• Three basic Types of inhalation Injury
• CO Poisoning
• Injury above the Glottis
• Injury Below the glottis
• Onset of S/S of inhalation injury in
  unpredictable enough that these patients should
  be generally be observed for 24 hours.

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Inhalation Injuries

• Most fatalities reported at fires are secondary
  to inhalation injuries
• CO Binds to Hemoglobin with approx. 100 times
  stronger bond than does O2
• Carboxyhemoglobin levels are found in excess of
  50-70 in such patients.
• Levels of 40-60 may cause mental status changes

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Inhalation Injuries

• Except for rare events, thermal inhalation
  injuries are limited to the upper airways
• When damage does occur, it is often severe enough
  to cause airway obstructions.
• This may occur at any time during the
  resuscitation
• In the case of hypotension/hypovolemia, the onset
  of edema may be delayed until perfusion is
  restored.

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Inhalation Injuries

• Warning signs can be subtle. Suspicions based
  on
• Hx of event
• Mental Status
• Voice
• Lung sounds
• Assessment findings
• Pediatrics are especially high risk secondary to
  their small airways.

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Inhalation Injuries

• Early treatment includes high flow O2, Humidified
  if possible
• Liberal use of Nasal ETT or RSI and oral ETT
  placement early in the care plan
• Aggressive pain control
• Hyperbaric Chambers are of unproven value.

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Circumferential Burns

• Circumferential Burns, or near circumferential
  burns, especially predominately 3rd degree burns,
  cause swelling to underlying tissues
• This swelling impairs respiration, circulation
  and function.
• This can cause permanent complications and death.

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Circumferential Burns

• Of Main concern are circumferential burns to the
  chest.
• As swelling increases the mechanics of
  respiration are impaired, the patient will become
  even more hypoxic and die.
• This is even more rapid in children who have poor
  respiratory reserves.

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Circumferential Burns

• Treatment is an Emergent Pre-Hospital Escharotomy
• This should be done after Pneumothorax,
  ETT/D.O.P. E. , and other issues are considered,
  however the progression to this treatment should
  be rapid.

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Electricity

• Safety is first. Go home at the end of your
  shift.
• Electrical burns can cause a path of destruction
  from entrance and exit wounds that may not be
  readily apparent.
• Cardiac, Renal, and Electrolyte problems are
  major concerns.
• ALS observation is advised.

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Electricity

• With lightning strikes, pt.s who are in cardiac
  arrest are frequently revivable.
• The heart usually spontaneously converts from
  asystole/VF back to a perfusing rhythm, but it
  may take some time for the respiratory drives to
  recover

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Chemical Burns

• May cause problems unrelated to the burns
  (Hydrofluoric Acid)
• May be difficult to stop the burning process
  (Chlorine GasHydrochloric Acid)
• May have to chose between the lesser of two evils
  (Rapid decon vs. Treatment, Bicarb nebs, etc)

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Age (Very Old or Young)

• The very old (gt55) and the Young (lt12)
• Pts less than 2 have an immature immune system
• Patients less than 12 have poor respiratory
  reserves
• Older patients have degenerative processes that
  lead to prolonged recover, not accounting for
  other medical problems
• All skin can be presumed to be thin in children
  younger than five years and in adults older than
  55 years. It is best to assume that there are no
  superficial partial thickness burns in these age
  groups

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Pre-Existing Disease

• Renal Failure Even Patients that do not have
  acute renal failure, but may have risk factor for
  such, may be thrown into renal failure either by
  the burn process or by the Hypoperfusion state
  that develops
• Hyper K is a risk as well (after 36 hours)
• Diabetes
• Cardiac Problems
• Respiratory problems

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Abuse/Intentional Burns

• May be young, Old , or the disabled. May be
  domestic in nature.
• Suspected abuse patients should be transported
  when ever possible
• Document thoroughly but objectively
• Do not press to hard , the important thing is to
  get the patient to the hospital, be careful not
  to prompt a refusal
• Be aware of psychological issues and act
  accordingly
• Be aware that some of these injuries may be
  cultural in nature (cupping, coining)

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Abuse/Intentional Burns

• burns
• scalding (most common burn injury)
• range from first to third degree in severity
• usually include splash burns
• accidental burns from hot, liquid spills usually
  more severe on upper body than lower body because
  liquid cools while flowing down - occur usually
  on front of body

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Abuse/Intentional Burns

• be suspicious - scald burns on back well defined,
  uniform 2nd-3rd degree burns on buttocks,
  extremities
• immersion burns
• inflicted maybe as punishment for toileting
  mishaps
• may be seen on buttocks
• on extremities - stocking or glove appearance
  where feet, hand dipped into hot water

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Abuse/Intentional Burns

• imprint burns
• caused by hot object held to skin - like
  cigarette or curling iron
• child usually moves away from hot object before
  receiving serious burns (accidental burn will
  usually be a single linear mark instead of full
  imprint which leaves outline - usually found on
  palm of hand where child grasps hot object)
• be suspicious - burns on back of hand
• cigarette burns usually 5-7 mm in diameter, well
  defined, deep puncture lesion under cigarette
  burn scab

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Other injuries treated as burns

• Bed sores
• Frost Bite
• Gangrene

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Referral Criteria

• 2nd or 3rd Degree Burns gt10 BSA
• Burns to Face, Hands , Feet, Genitailia,
  Perineum, or major Joints. ESPECIALY
  CIRCUMFRENTIAL BURNS
• Electrical Burns
• Chemical Burns
• Inhalation Injury

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Referral Criteria

• Burns with pre-existing PMHX that could
  complicate recovery
• Concomitant trauma (If Major Trauma, The Trauma
  Center , Not the Burn Center should be the
  initial stabilizing unit)
• When in doubt , consult with a burn center

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Questions?