Chapter 12: Burns

Lecture

I. Introduction
	Time: 3 Minutes
	Slides: 1–2
	Lecture/Discussion
A. 	According to the American Burn Association there are approximately 1 million burn injuries per year in the United States. 
1. 	In the year 2000, there were 125 burn centers in the United States with an average of 200 admissions per year.  
2. 	The average size of a burn injury that requires admission is 14% of the total body surface area (TBSA).
a. 	Six percent of burn center admissions do not survive. 
b. 	Highest incidence of burns occurs in the first few years of life and between 20 to 29 years of age. 
c. 	Serious burns occur most often in males; most burns are caused by flame.
B. 	Most admissions to burn centers require transport via EMS to specialized care. 
1. 	First 24 hours of care after a burn are crucial
C. 	Critical care transport professionals (CCTPs) must be able to handle complications of burns that may occur during transport. 
D. 	Chapter focus includes:
1. 	Anatomy and function of skin
2. 	Physiology of burns
3. 	Classification of burn injury
4. 	Assessment
5. 	Management
6. 	Special situations

II. Anatomy and Function of the Skin
	Time: 14 Minutes
	Slides: 3–11
	Lecture/Discussion
A. 	The skin is the largest organ of the body. 
1. 	Epidermis and dermis are main components of skin
2. 	Epidermis and dermis each have several levels with specific functions
B. 	Epidermis
1. 	Four layers (thin skin), except on the palms, fingertips, and soles of feet
2. 	Five layers (thick skin) on palms, fingertips, and soles of feet 
a.	 Stratum basale (attached to the dermis)
b. 	Stratum spinosm (prickly layer)
c. 	Stratum granulosm
d. 	Stratum lucidum (thick skin only)
e. 	Stratum corneum
i. 	Prevents water loss from deeper structures
ii. 	Constantly sloughs off dead cells
iii. 	Takes approximately three weeks for a skin cell to become a keratinocyte and be shed
iv. 	First barrier to injury
C. 	Dermis
1. 	Lies beneath the epidermis
2. 	Cell types include fibroblasts, macrophages, white blood cells, and mast cells.
3. 	Contains nerve fibers, blood vessels, lymphatic vessels, hair follicles, and oil and sweat glands
4. 	Papillary layer
a.	Anchors the epidermis
b. 	Heavily laden with blood vessels
5. 	Reticular layer
a. 	80% of the dermis
b. 	Dense connective tissue makes skin durable and anchors appendages.
c.	Form lines of cleavage
d. 	Interlocking collagen fibers run in various planes, usually parallel to the skin.
e. 	Hypodermis contains subcutaneous fat, connective tissue, sweat glands, muscle, and bone.
D. 	Process of healing
1. 	Fibroblasts produce proteins such as collagen and fibronectin responsible for skin repair.
2. 	Macrophages are normally present in the tissues but increase in numbers after an injury.
a. 	Release chemical messages that attract other cells and orchestrate healing
3. 	Endothelial cells produce capillaries and restore blood flow after an injury.
E. 	Functions of skin
1. 	Multiple functions
a. 	Protection (maintains fluid balance)
b. 	Immunologic (prevents entry of bacteria)
c. 	Thermoregulation (Large burns can cause hypothermia.)
d. 	Fluid and electrolyte balance
e. 	Metabolism
f. 	Neurosensory (Burn victims may lose the ability to feel pain, or burns can cause great pain.)
g. 	Social
2. 	Any burn can compromise the functions of the skin.

III. Physiology of Burns
	Time: 6 Minutes
	Slides: 12–16
	Lecture/Discussion
A. 	Causes of burns
1. 	Flame/flash
2. 	Scald (water or grease)
3. 	Contact
4. 	Electrical
5. 	Chemical
6. 	Radiation
7. 	Thermal
a. 	Thermal burns having temperatures of 113ºF can cause cell damage and denaturing of cellular proteins.
b. 	A temperature of 120ºF can cause a full-thickness burn in 5 minutes.
c. 	A temperature of 159ºF can cause a full-thickness burn in 1 second in a healthy adult.
8. 	Some diseases cause burnlike injuries.
B. 	All burns cause destruction of skin and impairment of function.
C. 	Anatomy of a burn
1.	Zone of coagulation—skin that came into direct contact with the heat source
2. 	Zone of stasis—has injured tissue and stagnant blood flow resulting in ischemic tissues (tissues with reduced blood flow); possibility of tissue death
3. 	Zone of erythema—area of increased blood flow; minimal damage and likely to recover
D. 	Systemic inflammatory response of burned patient
1. 	Some inflammation is normal and necessary
2. 	Excessive inflammation can cause problems for other tissues and organs.
3. 	Burns of greater than 25% TBSA result in systemic inflammatory response.
4. 	Problems associated with systemic inflammatory response
a. 	Proteins may leak into subcutaneous tissues at uninjured sites, or the pressure at which proteins may be exuded into the lungs may be lowered, increasing the chance of pulmonary edema.
b. 	Immune system suppression
c. 	Leaky endothelial cells in the intestine may allow bacteria to enter the bloodstream.
d.	Reduced cardiac output

IV. Classification of Burn Injury
	Time: 23 Minutes
	Slides: 17–31
	Lecture/Discussion
A. 	Burn extent and depth
1. 	Superficial or first-degree burns
a. 	Involve only epidermis
b. 	Result of ultraviolet light exposure (sunburn), minor scald injuries, or flash burns
c. 	Healing usually occurs without scarring in 7 days
2. 	Partial-thickness or second-degree burns
a. 	Superficial partial-thickness burns—epidermis and part of the dermis are involved; deeper layers of the dermis are spared
i. 	Caused by hot liquids or minimal contact with flame
ii. 	Often have blisters
iii. 	Heal in 14 to 21 days
iv. 	Some scarring possible
b. 	Deep partial-thickness burns
i.  	The result of steam, oil flames
ii. 	Involve deeper layers of the dermis
iii. 	Difficult to distinguish from full-thickness burns
iv. 	Skin is blistered but not charred
v. 	Healing takes 21 days or more; may require grafts
vi. 	Scarring is moderate 
3. 	Full-thickness or third-degree burns
a.	Involve the entire thickness of the dermis down to the subcutaneous fat
b. 	Epidermal and dermal structures, including nerve endings, are destroyed.
c. 	Skin grafts are necessary
d. 	Significant scarring
4. 	Subdermal or fourth-degree burns
a.	Involve deep structures of muscle and bone, larger blood vessels, and nerves
b. 	Injuries are severe and life threatening
c. 	Require surgical intervention 
B. 	Burn size
1. 	Rule of nines
a. 	Used for adults 
b. 	Based on principle that body can be divided into areas that represent 9% of the TBSA
2. 	Lund and Browder chart
a. 	Preferred method
b. 	Chart is difficult for emergency care workers to memorize
C. 	Burn severity
1. 	Major
a. 	Partial-thickness burns involving more than 25% of TBSA (adults) or 20% of TBSA for children under 10 and adults over 50.
b. 	Full-thickness burns involving more than 10% of TBSA
c. 	Burns involving face, eyes, ears, hands, feet, or perineum
d. 	Burns caused by chemical agents
e. 	High-voltage electrical injury
f. 	Burns with inhalation injury or major trauma
g. 	Burns sustained by high-risk patients
2. 	Moderate
a. 	Partial-thickness burns involving more than 15% to 25% of TBSA (adults) or more than 10% to 20% of TBSA for children under 10 and adults over 50.
b. 	Full-thickness burns involving 2% to 10% of TBSA that do not present a serious threat to functional or cosmetic impairment of eyes, ears, face, hands, feet, or perineum
3. 	Mild
a. 	Partial-thickness burns involving less than 15% of TBSA (adults) or less than 10% of BTSA for children under 10 and adults over 50.
b. 	Full-thickness burns involving less than 2% of TBSA that do not present a serious threat to functional or cosmetic impairment of eyes, ears, face, hands, feet, or perineum

V. Assessment
	Time: 24 Minutes
	Slides: 32–47
	Lecture/Discussion
A. 	General	
1. 	Perform complete initial assessment, focused history, and physical exam
2. 	Use caution if c-spine injury is suspected.
3. 	Do not rely on history and exam of others because training may not be equivalent.
B. 	Initial assessment	
1. 	Airway
a. 	Needs special attention
b. 	Inhalation of gases, particles, and other debris can damage respiratory epithelium.
i. 	Inflammatory changes to the airway occur within 2 hours of injury.
c. 	If inhalation injury is present, consider intubation.
d. 	Evidence of inhalation injury
i. 	Facial burns
ii. 	Stridor or progressive hoarseness
iii. 	Singeing of the eyebrows and nasal vibrissae
iv. 	Carbon deposits and acute inflammation of the oropharynx
v. 	Carbonaceous (black) sputum
vi. 	History if impaired mentation and/or confinement in a burning environment
vii. 	Explosion with burns to the head and torso
viii. Circumferential neck burns
ix. 	Carboxyhemoglobin level greater than 10% if the patient is involved in a confined space fire
x. 	Soot around nose and mouth
2. 	Breathing
a. 	Noncardiogenic pulmonary edema may result from inhalation injury or fluid overload.
b. 	Start high-flow oxygen immediately; use caution with people who have chronic obstructive pulmonary disease (COPD).
c. 	Examination of chest should include search for circumferential burns
d. 	Be careful not to overlook pneumothorax or hemothorax.
e. 	Patients with carbon monoxide poisoning may have hypoxia.
f. 	Cyanide poisoning should be considered if patient has intense air hunger, metabolic acidosis, or sudden cardiovascular collapse, and the patient has been in a confined space fire.
3. 	Circulation
a. 	Burn patients may have impaired circulation.
b. 	Hemoglobin levels of 10g/dL preferred for flight
c. 	Evaluate extremities and digits for circumferential burns.
d.	Identification of circulatory problems is important for preventing amputation.
e. 	Compartment syndrome
i. 	Pain
ii. 	Pallor
iii. 	Paralysis
iv. 	Paresthesias
v. 	Pulselessness
f. 	Fluid resuscitation should be guided by formulas such as the Galveston and Parkland formulas.
C. 	Focused history and physical exam	
1. 	Disability
a. 	Burn patients are usually awake and alert.
b. 	Unconscious or confused patients may have issues affecting their mental states.
c. 	CCTP should watch for changes in mental state.
2. 	Exposure
a. 	Head-to-toe examination of patient is necessary
b. 	Remove dressings and examine wounds prior to transport.
c. 	Assess the patient for hypothermia.
D. 	History
1. 	Detailed history must include information about the patient, the incident, and treatment that has been provided.	
2. 	Patient information (SAMPLE)
a.	Signs/symptoms
b. 	Allergies
c. 	Medications
d. 	Past medical and surgical history/tetanus status
e. 	Last meal or drink
f. 	Events leading to injury
3. 	Mechanism of injury
a. 	Source of burn
b. 	Closed space and duration of exposure
c. 	Chemical exposure
d. 	Related trauma
4. 	Prior interventions
a. 	Scene
i. 	Resuscitation required and fluid administered
ii. 	Field decontamination
b. 	Hospital
i. 	Tetanus booster
ii. 	Fluids given
iii. 	Other treatments (sedation, medications)
iv. 	Procedures (central line placement, escharotomy)
5. 	Bring copies of records to the transferring facility.

VI. Management
	Time: 23 Minutes
	Slides: 48–62
	Lecture/Discussion
A. 	Stopping the burn
1. 	Remove patient from source of burn
2. 	Cooling effective within first two minutes; do not continue after 20 to 30 minutes
3. 	Blisters left intact except for chemical burns
4. 	Irrigation
a. 	Indicated for chemical burns; should be guided by pH of the wound
i. 	Irrigation should continue for 20 minutes.
b. 	Also beneficial for burns caused by molten materials, synthetic materials, or tar
5. 	Remove clothing and jewelry.
6. 	Patient should be kept warm and placed in clean, dry linens.
B. 	Airway and breathing
1. 	Assess patient for inhalation injury.
a. 	If required, perform endotracheal intubation or other surgical airway intervention.
b. 	If patient is hemodynamically unstable, consider sedation.
2. 	Airway management in a burn patient is difficult.
a. 	Airway edema can make intubation difficult.
b. 	Many devices are not designed to work with patients who have no glottic opening.
3. 	Carbon monoxide poisoning, asphyxiation, and cyanide poisoning
a. 	Treat patient with 100% oxygen via nonrebreathing mask.
b. 	Patient should be monitored closely for hypoventilation.
c. 	Attempts to oxygenate the patient to suprabaseline oxygenation levels can result in carbon dioxide retention, acidosis, arrhythmias, and respiratory arrest.
C. 	Circulation
1. 	Early, aggressive, sustained fluid management necessary
2. 	Burns can result in large intravascular fluid losses.
a. 	No protection against desiccation and evaporation
b. 	Circulating inflammatory mediators can cause fluid loss from capillaries into interstitial spaces.
3. 	Fluid resuscitation
a. 	Parkland formula is most widely used
b. 	May be necessary to administer fluids more aggressively if patient is in shock or has unstable vital signs
c. 	Galveston formula more suitable for children—uses BSA burned and TBSA instead of weight to calculate fluid needs.
d. 	Carefully monitor urine appearance and output.
D. 	Wound management and dressing
1. 	After cooling, irrigating, and decontaminating, wounds should be dressed with clean, dry dressings. 
2. 	Blisters should be left intact unless caused by a chemical burn.
3. 	Tar and asphalt 
a. 	Tar must be removed because it can cause infection.
i. 	Aromatic hydrocarbons (benzene, toluene, and naphthalene) are effective for removing tar.
b. 	Napthalene, hexane, and other carbon solvents are useful for removing asphalts.
c. 	Solvents used to remove tar and asphalt are toxic.
d. 	Ointments and creams are unnecessary, but they can be left in place if already present.
4. 	Debridement (removal of dead tissue) should not be performed by CCTP except in instances of chemical exposure.
E. 	Wound infections and treatment
1. 	Infection does not occur for several hours.
a. 	No role for antibiotic prophylaxis by CCTP
b. 	Topical antibiotics may be used for dressing wounds.
2. 	Patients who have not had a tetanus booster in the last 5 years require diptheria and tetanus toxoids intramuscularly. 
3. 	Patients who have not had the primary series of immunizations will require tetanus immunization in addition to the primary series
F. 	Pain control
1. 	Pain from burns is excruciating.
2. 	Opioids are agents of choice in patients who are not allergic. 
3. 	Pain should be assessed every 10 minutes until the patient is comfortable.
a. 	Monitor patient for altered levels of consciousness.
4. 	CCTPs should be careful not to confuse sedation with analgesia.
5. 	All medications should be given intravenously.
G. 	Other issues
1. 	Hypothermia
a. 	Remove wet clothing, dressings, and linens. 
b. 	Dry sheets and blankets are preferred. 
c. 	Warm IV fluids should be used.
2. 	Gastric Decompression
a. 	Patients with greater than 20% TBSA are prone to ileus (loss of intestinal motility).
i. 	Narcotics also increase likelihood of ileus
b. 	Use nasogastric tubes.
c. 	Decompression of the stomach will reduce distension, discomfort, and vomiting.

VII. Special Situations
	Time: 17 Minutes
	Slides: 63–73
	Lecture/Discussion
A. 	Renal failure and rhabdomyolysis
1. 	Several causes of inadequate urine output
a. 	Shock
b. 	Rhabdomylosis (mobilization of muscle proteins impairing filtration by kidneys)
i. 	If urine output does not improve with fluid resuscitation, increase fluids, add sodium bicarbonate, and consider adding a diuretic such as mannitol.
2. 	Patients with preexisting cardiac and renal dysfunction may develop pulmonary edema and congestive heart failure as a result of aggressive fluid resuscitation.
a. 	Still better to err on the side of overresuscitation
b. 	Potassium-containing fluids should be avoided in patients with renal failure; use normal saline instead.
B.	Ocular burns
1. 	All burn patients should have a thorough eye exam.
2. 	Copious irrigation for chemical burns and airbag injuries
a. 	Irrigation should occur for 20 minutes.
b. 	Morgan lenses can be used for eye irrigation.
c. 	Lactated Ringer’s solution is best; normal saline is also acceptable.
C. 	Facial burns
1. 	Ocular and airway injuries are major concerns.
2. 	Face develops edema quickly.
3. 	To reduce facial edema, head of stretcher should be elevated 30º if no spinal injury is suspected.
D. 	Ear burns
1. 	Ear canal and eardrum should be examined before edema develops.
E. 	Circumferential burns and compartment syndrome
1. 	Burns that encircle the chest, an extremity, or the penis
a. 	May result in vascular compromise
2. 	These injuries may require an esharotomy.
a. 	An incision is made through stiff edematous burned skin to restore mobility to the chest or circulation to an extremity.
b. 	Should only be performed to save life or limb
c. 	Should be done only in consultation with the burn center
F. 	Hand and foot burns
1. 	Maintaining circulation is highest priority
2. 	Simple interventions such as elevation and avoiding constrictive dressings
3. 	Do not apply ice as it may cause frostbite.
4. 	Do not apply creams or ointments.
G. 	Genitalia burns
1. 	Burns on genitalia and perineum should not distract health care providers from life-threatening injuries. 
2. 	Foley catheter should be placed before edema develops
3. 	Penis should be examined for circumferential burns and impaired circulation
H. 	Pediatric burns and child abuse
1. 	Children have more surface area per kilogram.
2. 	Children have less glycogen stores than adults.
a. 	Consider administering glucose to resuscitation fluids, with advice from burn center
3. 	25% of all childhood burns are the result of child abuse. 
a. 	Accidental burns most likely on the face and chest.
b. 	Suspect child abuse if the burn was not reported within 24 hours.
4. 	All suspected child abuse must be reported to child protection authorities and the receiving facility.
I. 	Electrical burns
1. 	Alternating current
a. 	Found in most homes and businesses; most common
2. 	Direct current
a. 	Found in automobile systems and some lighting systems; also lightning
3. 	Electricity releases heat as it passes through or across the body. 
a. 	Hands most common entry
b. 	Feet most common exit
4. 	Damage to deep tissues not always evident
5. 	Cardiac arrest and renal failure possible
6. 	Lightning burns may leave extensive superficial cutaneous burns in a fern or reticular pattern.
J. 	Chemical burns
1. 	Caused by common household, industrial, and farm products
2. 	Patients should be completely disrobed and irrigated with copious amounts of water.
3. 	Do not attempt to neutralize the burn with another chemical.
4. 	Some chemicals may be absorbed into the skin and continue to burn tissues and other organs.
K. 	Toxic epidermal necrolysis syndrome and Stevens-Johnson syndrome
1. 	Reaction to certain medications, environmental allergens, and other unknown toxins
2. 	Stevens-Johnsons syndrome is believed to be an autoimmune disorder.
3. 	Treatment is supportive.