lesson 09

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

LessonLesson 9 9

Thermal TraumaThermal Trauma

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2

ObjectivesObjectivesAs a result of active participation in this lesson, As a result of active participation in this lesson,

you should be able to:you should be able to: Differentiate between critical and noncritical thermally Differentiate between critical and noncritical thermally

injured patientsinjured patients Differentiate the treatment needs of thermally injured Differentiate the treatment needs of thermally injured

patients based on depth of injury, body surface area patients based on depth of injury, body surface area involved, mechanism of burn, and coexisting injuries involved, mechanism of burn, and coexisting injuries and health conditionsand health conditions

Discuss the specific needs of thermally injured Discuss the specific needs of thermally injured patients related to fluid resuscitation, pain patients related to fluid resuscitation, pain management, and thermoregulationmanagement, and thermoregulation



WHO statistics for 2002 estimates 322,000 deaths WHO statistics for 2002 estimates 322,000 deaths worldwide due to smoke, fire, and flamesworldwide due to smoke, fire, and flames

A large percentage of burns are a result of intentional A large percentage of burns are a result of intentional injury, particularly against children, women, and the injury, particularly against children, women, and the elderlyelderly



Burns are not just isolated to skin; large burns Burns are not just isolated to skin; large burns are a multisystem injury capable of life-are a multisystem injury capable of life-threatening affects to the heart, lungs, threatening affects to the heart, lungs, kidneys, GI tract, and immune systemkidneys, GI tract, and immune system

Most common causes of death relative to Most common causes of death relative to burn injuries are complications and burn injuries are complications and respiratory failurerespiratory failure


ScenarioScenario

You are dispatched to a suburban home on a You are dispatched to a suburban home on a cool, sunny fall day in response to a potential cool, sunny fall day in response to a potential burn patient. The fire department also has burn patient. The fire department also has responded. On your arrival you are informed responded. On your arrival you are informed by a member of the fire department that the by a member of the fire department that the 35-year-old male patient used an accelerant 35-year-old male patient used an accelerant in a metal trash receptacle with intent to burn in a metal trash receptacle with intent to burn garbage and yard debris.garbage and yard debris.


Scenario: Scene Size-UpScenario: Scene Size-Up

What are the considerations for scene What are the considerations for scene safety?safety?

What are the potential injuries associated What are the potential injuries associated with this mechanism?with this mechanism?


ScenarioScenario

The scene has been secured by the fire The scene has been secured by the fire department. The patient is standing upright with department. The patient is standing upright with both arms extended and appears to be in both arms extended and appears to be in considerable pain and distress. Most of the considerable pain and distress. Most of the patient's upper torso is bare with the exception patient's upper torso is bare with the exception of small patches of burnt clothing that remain. of small patches of burnt clothing that remain. Most of the patient’s hair has been burned off, Most of the patient’s hair has been burned off, and you can see varying skin discolorations and you can see varying skin discolorations from your vantage point.from your vantage point.


Primary SurveyPrimary Survey

Patient is awake, is in obvious pain, and has Patient is awake, is in obvious pain, and has great difficulty responding verbally.great difficulty responding verbally.

You note sounds of stridor on inspiration.You note sounds of stridor on inspiration. You determine the presence of reddened skin You determine the presence of reddened skin

and blistering to the anterior chest and upper and blistering to the anterior chest and upper extremities, and what appears to be ‘raw’ extremities, and what appears to be ‘raw’ flesh in the neck and facial area. All facial hair flesh in the neck and facial area. All facial hair and most scalp hair has been burned off.and most scalp hair has been burned off.


Scenario: Critical ThinkingScenario: Critical Thinking

Does your assessment of this Does your assessment of this patient indicate an inhalation patient indicate an inhalation injury?injury?

How does this affect your How does this affect your treatment of this patient?treatment of this patient?


Inhalation InjuryInhalation Injury

ThermalThermal Dry air vs. steamDry air vs. steam

Asphyxiation/smoke inhalationAsphyxiation/smoke inhalation Carbon monoxideCarbon monoxide Cyanide gasCyanide gas Particulate matterParticulate matter

Delayed toxin-induced lung injuryDelayed toxin-induced lung injury May manifest after several daysMay manifest after several days Severity related to composition of inhaled gas Severity related to composition of inhaled gas

and duration of exposureand duration of exposure


Signs of Inhalation InjurySigns of Inhalation Injury

Singed or absent facial hairSinged or absent facial hair Facial burnsFacial burns Difficulty speaking, hoarseness, or stridorDifficulty speaking, hoarseness, or stridor Soot in oropharynxSoot in oropharynx Oropharyngeal edemaOropharyngeal edema Crackles auscultated in lungsCrackles auscultated in lungs Respiratory failureRespiratory failure


Inhalation Injury: TreatmentInhalation Injury: Treatment

Early intubation Early intubation before airway before airway becomes occludedbecomes occluded

High-flow oxygenHigh-flow oxygen Rapid transport to Rapid transport to

an appropriate an appropriate facilityfacility

Early and aggressive Early and aggressive airway management is airway management is critical for patients critical for patients with inhalation injury!with inhalation injury!


Scenario: TreatmentScenario: Treatment

Stop the burning process!Stop the burning process! What are the patient’s immediate airway What are the patient’s immediate airway

needs?needs? Does this patient require assisted Does this patient require assisted

ventilations?ventilations?



What degree/thickness of burns are likely in What degree/thickness of burns are likely in this patient?this patient?

Which type of injury is likely causing your Which type of injury is likely causing your patient’s pain?patient’s pain?

Does the degree/thickness of burns alone Does the degree/thickness of burns alone make this a critical patient?make this a critical patient? Why or why not?Why or why not?


Fluid ResuscitationFluid Resuscitation Most critical to preventing hypovolemic shock; Most critical to preventing hypovolemic shock;

second only to airway in early burn treatmentsecond only to airway in early burn treatment Preference is for lactated Ringer’s solutionPreference is for lactated Ringer’s solution Avoid starting IVs in burned tissue, where Avoid starting IVs in burned tissue, where

edema can make veins difficult to find and lines edema can make veins difficult to find and lines difficult to securedifficult to secure

Patients with both thermal and smoke inhalation Patients with both thermal and smoke inhalation require additional fluids over what would be require additional fluids over what would be given patient with thermal burns only; given patient with thermal burns only; withholding fluids aggravates the severity withholding fluids aggravates the severity of pulmonary injuryof pulmonary injury


Fluid Resuscitation: Fluid Resuscitation: Parkland FormulaParkland Formula

Calculates the fluid required during the initial 24 Calculates the fluid required during the initial 24 hours from point of injuryhours from point of injury 4 mL/kg/%TBSA burn4 mL/kg/%TBSA burn Divide the 24-hr value by 2 to determine fluid value to Divide the 24-hr value by 2 to determine fluid value to

be given from time of injury to hour 8be given from time of injury to hour 8 Divide total by 8 for hourly rateDivide total by 8 for hourly rate


Critical ThinkingCritical Thinking

Is this patient’s circulation compromised?Is this patient’s circulation compromised? Calculate appropriate fluid resuscitation for a Calculate appropriate fluid resuscitation for a

patient weighing 80 kg and with 36% body patient weighing 80 kg and with 36% body surface area burns using the Parkland surface area burns using the Parkland formula.formula.

How would you administer these fluids?How would you administer these fluids?


Anatomy of the SkinAnatomy of the Skin

Epidermis Epidermis (outermost layer)(outermost layer)

Dermis Dermis (nerve endings, (nerve endings, blood vessels)blood vessels)

Subcutaneous Subcutaneous (fat and muscle)(fat and muscle)


Determining the Severity of BurnsDetermining the Severity of Burns

First-Degree or Superficial BurnsFirst-Degree or Superficial Burns Involves the epidermisInvolves the epidermis Red and painfulRed and painful

Second-Degree or Partial-Thickness BurnsSecond-Degree or Partial-Thickness Burns Involves the epidermis and potentially some portion of Involves the epidermis and potentially some portion of

the dermisthe dermis Blisters and/or glistening or wet baseBlisters and/or glistening or wet base

Third-Degree or Full-Thickness Third-Degree or Full-Thickness BurnsBurns

Thick, dry, white leatheryThick, dry, white leathery Visible thrombosis of blood vesselsVisible thrombosis of blood vessels

Fourth-Degree BurnsFourth-Degree Burns Involves all layers of skin, fat, bone, Involves all layers of skin, fat, bone,

and underlying organsand underlying organs



What degree/thickness of burns does your What degree/thickness of burns does your observation of this patient indicate?observation of this patient indicate?

Which of these values is likely causing your Which of these values is likely causing your patient’s pain?patient’s pain?

Do these values alone indicate a critical patient? Do these values alone indicate a critical patient? Why or why not?Why or why not?


Rule of NinesRule of Nines



What percent of body surface area (BSA) What percent of body surface area (BSA) burns does your observation of this patient burns does your observation of this patient indicate?indicate?

Does this value alone indicate a critical Does this value alone indicate a critical patient? Why or why not?patient? Why or why not?

How does this value affect your treatment?How does this value affect your treatment?


Complicating FactorsComplicating Factors

Age/genderAge/gender Chronic diseaseChronic disease Circumferential burnsCircumferential burns Distracting injuryDistracting injury Fluid lossFluid loss [Already compromised] Immune system[Already compromised] Immune system


Scenario: Scenario: How would you treat this patient?How would you treat this patient?

Stop the burning process!Stop the burning process!

What are the patient’s airway needs?What are the patient’s airway needs?

Does this patient require assisted ventilations?Does this patient require assisted ventilations?



What can be done to improve the patient’s What can be done to improve the patient’s circulation?circulation?


Wound DressingWound Dressing Dry sterile dressingsDry sterile dressings Wet dressings only when BSA is less than 10%Wet dressings only when BSA is less than 10% Keep burn areas covered to reduce painKeep burn areas covered to reduce pain Do not remove clothing that has adhered to skinDo not remove clothing that has adhered to skin Do not break blisters prehospitalDo not break blisters prehospital Do not apply ointments, salves, or gelsDo not apply ointments, salves, or gels



What kinds of wound dressings would you What kinds of wound dressings would you apply to this patient?apply to this patient?

Is the loss of body heat a consideration with Is the loss of body heat a consideration with this patient?this patient?



Does this patient require pain management?Does this patient require pain management?


Pain ManagementPain Management

Ensure afflicted areas are coveredEnsure afflicted areas are covered Airflow across burn area causes painAirflow across burn area causes pain

Follow local protocols for pharmacological Follow local protocols for pharmacological interventionsinterventions



What transport decisions are involved with this What transport decisions are involved with this patient?patient?


Chemical BurnsChemical Burns Can be classified as:Can be classified as:

AcidAcid——pH of 7 (neutral) to 0 pH of 7 (neutral) to 0 (strong acid)(strong acid)

BaseBase——pH of 7 to 14pH of 7 to 14 Organic (i.e., gasoline)Organic (i.e., gasoline) Inorganic (i.e., hydrofluoric acid)Inorganic (i.e., hydrofluoric acid)


Chemical BurnsChemical Burns

Ensure scene safety for you, your partner, Ensure scene safety for you, your partner, and your patientand your patient

Wear protective gearWear protective gear In In mostmost cases, flushing the affected area with cases, flushing the affected area with

copious amounts of water will dilute and copious amounts of water will dilute and remove the chemicalremove the chemical Powdered chemicals should be brushed off firstPowdered chemicals should be brushed off first


Chemical BurnsChemical Burns

If protocol is unknown, contact the nearest If protocol is unknown, contact the nearest poison control centerpoison control center

Material Safety Data Sheets (MSDS) should Material Safety Data Sheets (MSDS) should be transported along with patientbe transported along with patient

Chemical burns of the eyes should be flushed Chemical burns of the eyes should be flushed with water continuouslywith water continuously Morgan lens is a useful adjunctMorgan lens is a useful adjunct

Treat all chemical burn patients as criticalTreat all chemical burn patients as critical


Electrical BurnsElectrical Burns

Can be classified as:Can be classified as: Current burns Current burns Arc (flash)Arc (flash)Contact burnsContact burns


Electrical BurnsElectrical Burns Injury can include:Injury can include:

Thermal burnsThermal burns Altered mentationAltered mentation Intracranial bleedingIntracranial bleeding Partial or full paralysisPartial or full paralysis Cardiac arrhythmiasCardiac arrhythmias Kidney failureKidney failure Associative injuriesAssociative injuries

• Ruptured tympanic membranesRuptured tympanic membranes

• Spinal and long bone fracturesSpinal and long bone fractures


Electrical Burns Electrical Burns

Ensure scene safety for you, your partner, Ensure scene safety for you, your partner, and your patientand your patient

Immobilize spine if fractures are detected or Immobilize spine if fractures are detected or suspectedsuspected

Administer IV lactated Ringer’s or normal Administer IV lactated Ringer’s or normal saline to flush myoglobin and prevent kidney saline to flush myoglobin and prevent kidney damagedamage


Patients Requiring Burn CentersPatients Requiring Burn Centers Inhalation injuryInhalation injurySecond/third-degree burns in children under 10 Second/third-degree burns in children under 10

years of age or adults older than 50 years of ageyears of age or adults older than 50 years of ageSecond/third-degree burns of more than 20% Second/third-degree burns of more than 20%

TBSATBSASecond/third-degree burns involving face, hands, Second/third-degree burns involving face, hands,

feet, genitalia, perineum, and major jointsfeet, genitalia, perineum, and major joints


Patients Requiring Burn CentersPatients Requiring Burn CentersSecond/third-degree burns with complicating Second/third-degree burns with complicating

trauma where burn poses greatest risktrauma where burn poses greatest riskChemical burnsChemical burnsElectrical burnsElectrical burnsPatients with preexisting medical disordersPatients with preexisting medical disorders


SummarySummary

Thermal trauma is a significant cause of Thermal trauma is a significant cause of morbidity and mortalitymorbidity and mortality

Immediate concerns are for airway, breathing, Immediate concerns are for airway, breathing, and circulationand circulation

Large burns are a multisystem problemLarge burns are a multisystem problem EMS providers play a critical role in EMS providers play a critical role in

recognizing burn center criteria and in the recognizing burn center criteria and in the initial management of burn patientsinitial management of burn patients


QUESTIONS?QUESTIONS?

lesson 09

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