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PLEASE NOTE

Burns

In light of the Black Saturday bushfires some students may find the following topic to be distressing. Students who feel they would be more comfortable not attending the lecture are welcome to make a time to see me if they require clarification of the notes. If you are experiencing continued distress please contact Student counselling services on 9919 2399 or a Victoria University /AV Peer Support staff member.

HFB 2216 Paramedic Clinical Science 2 Liz Thyer Room 3s20 Elizabeth.thyer@vu.edu.au

Learning Objectives

Learning Objectives

Describe the pathophysiological response to and systemic complications of burn injury. Classify burn injury according to established standards. Describe the pre-hospital management of the patient who has a burn injury. Review the major functions of the integumentary system system. Describe the epidemiology, incidence risk factors, and prevention strategies of burn injuries. Identify and describe types of burn injuries, including a thermal burn, an inhalation burn, a chemical burn, an electrical burn, and a radiation exposure.

Identify and describe methods for determining body surface area percentage of a burn injury including the "rules of nines," the "Lund and Browder" chart and other methods Differentiate criteria for determining the severity of a burn injury between a paediatric patient and an adult patient. Discuss conditions associated with burn injuries, including trauma, blast injuries, airway compromise, respiratory compromise, and child abuse. Describe the management of a burn injury

Readings

Epidemiology

Sanders Ch 23 McCance Ch 45

Approximately 1% of the population of Australia and New Zealand (220,000) suffer burns each year. 50% of those will suffer some daily living activity restriction. 10% will require hospitalisation. 10% of these are in severe life threat. A severe burn may cost in the order of $250,000 for the acute hospital care and rehabilitation as well as time off work.

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Epidemiology

Epdemiology
INJURED BY BURN OR SCALD by Age group - 2001

Burns constitute only small proportion of all injury deaths in Australia. People aged 15-24 reported the highest rate of burns. House fires were the dominant cause of burn deaths in 1995 (69%) and a third of the deaths from this cause were children aged less than 15 years.

Burns
Cause of burns: Carelessness Accident Other combined Place of burning: Home Work Roadway Outdoors 42% 36% 22%

Burns
Cause of burn: Explosion / flame Scald oil/water Contact Electrical Chemical Friction or sun

61% 17% 10% 8%

48% 33% 8% 5% 3% 3%

Pathophysiology

Burn Classifications

Skin is the largest organ in the body Functions

To prevent water loss via evaporation body s bodys major barrier against infection Temperature regulation

When classifying burns in the prehospital field consideration is made for the following:

Pathophysiological effect will be dependent upon the surface area covered by the burn and the depth of the burn

Depth Surface area Location Cause

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Burn Classifications

Superficial Burns

Burns classifications according to depth can be made into three types: Superficial (old terminology first-degree)

Partial thickness (old terminology seconddegree) Full thickness (old terminology thirddegree)

Only involve the epidermis Pain and swelling normally subsides within 48 hours Usually fully healed within 7 days y y y Sunburn is an example Bullae may appear, but only after 24 hours

Partial Thickness

This involves the destruction of the epidermis and superficial dermis The burned area appears blistered Further classified as

superficial partial thickness and deep partial thickness

Partial Thickness

Full Thickness

Superficial partial thickness

Bright red and moist Very sensitive to stimulus Heal in 2-3 weeks Minimal scarring Dark red or yellow white Take longer than 3 weeks to heal hyper-trophic scarring occurs Few epithelial elements remain

Deep partial thickness

Involves the epidermis and dermis including the dermal appendages Burn appears charred or pearly white, brown or black colour, dry and leathery colour Normally without sensation, but can still be considerable pain to the patient. Because of the depth of the burn healing only occurs in the form of scarring or skin graft

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Burn Shock

Relative and absolute fluid loss Relative

Tissue Tiss e oedema Evaporation Cardiac output may drop by 30-50% resulting in cardiac depression

Absolute

Surface Area Classification

Wallace Rule Of Nines

Wallace Rule of nines

quick and easy to do usually quite accurate but this reduces with patient age high degree of accuracy for all ages but time consuming and not easily remembered

Lund and Browder charts

Palmar method

Lund And Browder Chart

Paediatric Rule of Nines

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Burn Classification Minor Burns

Burn Classification Moderate Burns

<10% TBSA in adult <5% TBSA in <10 yo or >50 yo <2% full thickness burns Patients can be managed at low acuity facilities

10-20% TBSA in adult 5-10% TBSA in <10 yo or >50 yo 2/5% full thickness burn High voltage injury Suspected inhalation injury Circumferential burn Concomitant medical problem Will need hospital admission
American Burn Association Grading System

American Burn Association Grading System

Burn Classification Major Burns

Burn Type Classification

Partial or full thickness with: TBSA >10% in patients < 10 or > 50 years old TBSA >20% in patients of any age group Full thickness burns of BSA > 5% High voltage burn Known inhalation injury Significant burn to face, hands, feet, genitalia, perineum or major joints Significant associated injuries Will need admission to a burn centre
American Burn Association Grading System

Thermal Chemical Electrical Radiation

Thermal Burns Thermal Burns

Most common type of burn Risk is highest in the 18 35 year olds High incidence of scalding in 1 5s Soft tissue is burned when it is exposed to temperatures above 45C ( lth t t b (although ti h time can influence burn, 44 >6hours =burn) Rate of dermal necrosis doubles with each degree rise 46-51, necrosis in <1 second at 70

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Thermal Burns

Thermal Burns

Thermal burns cause coagulation of soft tissue Leading to:

Three Distinct zones of injury:

Zone of coagulation

soft tissue temperature increases capillary permeability increases fluid loss occurs plasma viscosity increases resultant microthrombi formation

Centre of wound, area of most intense contact Coagulation necrosis of cells, nonviable Surrounds critically injured area potentially viable area, Ischaemic cells because of clotting and vasoconstriction, die within 24-48 hours At the periphery of the wound, viable Increased blood flow due to inflammatory response Recovers in 7-10 days if no infection or shock

Zone of Stasis

Burns cause an increased metabolic rate and energy metabolism, which could affect the patients presenting condition

Zone of Hyperaemia

Jacksons Burn Wound Model

Thermal Burns
Injury Initially brief decrease in blood flow to area and Arteriolar vasodilation Release of chemical mediators and vasoactive substances Cause increase in capillary permeability Fluid shift from intravascular space into injured tissue Na K pump also damaged Na into cells Water into cells Increase in osmotic pressure Causes increase of flow of fluid into wound Compromised cardiac output due to reduced VR, reduced peripheral blood flow and increased systemic vascular resistance

Thermal Burns

Chemical Burns

Normal process of evaporation of water to the environment is accelerated Fluid loss (shock) 8-12 hours Decreased venous return Decreased ca d ac output ec eased cardiac Increased vascular resistance Eventually:

Haemolysis Rhabdomyolysis Haemoglobinuria ARF Death

Majority of chemical burns are from acids and alkalis Acids Coagulation F Formation of a tough eschar that can limit f th ti f t h h th t li it further damage Alkalis Liquefactive necrosis Deeper penetration Also need to consider the toxicity of the substance

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Chemical Burns

Chemical Burns

Superficial

Face, eyes and extremities are most commonly affected by chemical burns Mortality rate is lower than for thermal burns but wound healing longer Mucous membrane irritation is common Signs and symptoms are generally agent specific Alkalis may result in burns which initially appear superficial but progress to full thickness over time

Itching, burning and pain

Partial thickness

Tissue oedema Bullae Damage to the dermis the extent depends on the chemical, extent and duration of contact

Full thickness

Chemical Burns - Treatment

Chemical Burns

If liquid, irrigate with copious fluids If powder, dust off patient and remove clothing as water may activate the chemical Chemical burns to the eye should be treated by running water over the injured eye with the eyelid held open for at least 15 minutes Always tilt the head so the unaffected eye is uppermost and does not come in contact with contaminated water. Irrigation should be continued during transport and until reaching specialist medical assistance DO NOT water irrigate calcium, lithium or magnesium burns

Metals

Molten metals thermal burns Sodium, Lithium, potassium, magnesium, calcium g p y and aluminium can ignite spontaneously in air Should NOT use water to put it out as intensive exothermic reaction takes place Burning metal on the skin or hand should be covered with mineral oil or sand

Electrical Burns

Electrical Burns

When attending a casualty exposed to electricity, safety is the priority. Electrical injuries are divided into three categories:

low voltage high voltage g o age lightning strikes 1000v will clear a few millimetres. 5000v will bridge 10mm 40,000v will clear 130mm.

Low voltage is anything below 1000 volts. Domestic AC will cause significant contact wounds and may cause cardiac arrest but no deep tissue damage. High voltage is often 11,000 to 33,000 volts from high tension cables and can cause i j t i bl d injury i t in two ways

High voltage electricity will discharge through air.

Flash over discharge passes over the body igniting clothing but not causing contact wounds. Current transmission results in both surface and deep burns especially at the entry and exit points.

Deep muscle damage may occur under apparently normal skin and may be very extensive and life threatening.

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Lightning Strikes

Electrical Burns

Lightning strikes are extremely high voltage Also high amperage DC discharge of ultra short duration Lightening injuries have a 25% mortality rate and water sports accounts for the largest group of injuries and fatalities Significant injury especially with exit burns to the feet Pathway of damage often over rather than through skin

Three largest risk groups are toddlers teenagers those who work with electricity Severity related to: Current type Volts Intensity Resistance Area Duration of contact Environmental factors

Electrical Burns - Symptoms

Electrical Burns

Contact burns Thermal heating Flash arc and flame thermal burns Blunt trauma Prolonged muscle tetany Skin injury does not correlate well with underlying damage Low V = VF High V = Asystole Dysrhythmias can occur up to 24 - 48 hrs later

Electrical Burns Treatment

Prehospital Burns Management

As for thermal burns MICA Monitor/ECG

Non accidental injury

Emergency responders should be observant to situations where the injury appears suspicious due to

Delay in call Vague or inconsistent history Presence of other trauma Certain patterns of injury Information should be passed onto the receiving hospital

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Prehospital Burns Management

Prehospital Burns Management

Stop the burning process

Remove clothing that is not adhered to patient

Cover the burns with clean cool cloth soaked in cool water this will dissipate the heat Continue cooling with running water to reduce heat and swelling, the useful range is between 8 and 25 degrees C l i d Celsius. D Douse with water f at l ih for least 20 minutes. Never totally immerse patient in cold water or apply ice packs to burn Prolonged exposure to cold water and ice should never be applied Elevation of the part

Hot or charred clothing should be removed as quickly as possible.

Consider removing jewellery if near burnt areas of the patient Cover Co er the burn with a clean sterile dressing and or b rn ith cling wrap After stabilising the patient

A thorough secondary survey Adequate analgesia Elevate extensively burned limbs whilst maintaining observation of pulse strength and capillary refill

Rapid transport to appropriate medical facility

Prehospital Burns Management

Assess and stabilise the airway

Supplemental oxygen 8L/min Signs of laryngeal oedema indicate a need to intubate

Assess and stabilise circulation

IV cannulation in bilateral cubital fossae

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Systemic Complications

Haemodynamic instability

Haemodynamic instability Respiratory system involvement Hypermetabolic response Dysfunction of other organ systems D f ti f th t Sepsis

Hypovolaemic shock associated with: Decrease in venous return Decreased cardiac output Increased vascular resistance

Renal failure may occur due to:

Haemolysis Rhabdomyolysis

Haemodynamic instability

Haemodynamic instability
Initial fluid formula in adults for emergency ambulance is: % of Burn Surface Area x Weight (kg) over 2 hours (from time of burn)

Fluid replacement for extended management follows set formula Parkland formula: Most commonly used:

4mls/kg x % BSA over 24 hours With half to be given in the first 8 hours after injury

Burn surface area measured as a percentage (partial and full thickness only). For example:

50% burn surface area x 80kg patient = 4000mls

This is NOT what is used in AV!

Normal Saline solution to be administered in two hours from time of burn.

Haemodynamic instability
Initial fluid formula in paediatrics for emergency ambulance is: 3x % of Burn Surface Area x Weight (kg) = amount of fluid in first 24hours

Respiratory system involvement

These are also known as inhalation burns The result of inhaling hot gases Inhalation injury increases mortality in ALL burns by up to 40% 45% of patient with burns to face will have an inhalation injury All suspected inhalation burns should be regarded as time critical

Burn surface area measured as a percentage (partial and full thickness only). For example:

3 x 50% burn surface area x 20kg patient = 3000mls Hartmanns solution with 1500ml to be administered in first 8 hours.

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Respiratory system involvement

Hypermetabolic response

Pulmonary injury and airway burns should be considered in the presence of the following:

History of fire in enclosed space or possible explosion Facial burns or singed nasal/facial hairs Carbonaceous sputum Oedema to face and airways Hoarse voice Stridor, wheezes and / or cough Obvious respiratory distress

Stress of the burn increases the nutritional and metabolic needs of the body Characterised by

Increase oxygen need Increased glucose use Protein and fat wasting

Signs and symptoms of pulmonary injury following an inhalation event, may be delayed for 12 24 hours

Secrete stress hormones to maintain homeostasis Heat production is increased to balance heat loss from the burned area Peak is 7-17 days

Dysfunction of other organ systems

Sepsis

Renal failure may occur due to:

Haemolysis Rhabdomyolysis Decreased fluid volume Drugs Gastric dilation and decreased peristalsis compounded by drugs Due to periods of hypoxia Fluid volume deficits Electrical burns

May arise from

GIT

Burn wound Pneumonia UTI Infection l I f ti elsewhere h

Nervous System

Immunologically the skin is the first line of defence therefore the body is open to bacterial infection Destruction of the skin also affects delivery of components of the immune system to their site of need

Hospital Management

References and Acknowledgements

Tetanus Nasogastic tube Escharotomy may be necessary for circumferential limb burns

http://www.alfred.org.au/burns_unit/ Jodie Limon

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