point of wounding: burn complications

Burn ComplicationsBurn Complications

Department of Combat Medic Training

C168W005

Terminal Learning ObjectiveTerminal Learning Objective

Given a burn casualty, treat the burn

IAW Prehospital Trauma Life Support Chapters 13 and 21 and the principles of

Tactical Combat Casualty Care.

Enabling Learning ObjectiveEnabling Learning Objective

Given a combat casualty suffering from burns,

assess a burn casualtyIAW Prehospital Trauma Life Support and the principles of Tactical Combat Casualty

Care Chapter 13.

Casualty AssessmentCasualty Assessment

Care Under FireThe priorities of Care Under Fire remain the same for

burn casualties as with any other combat casualty.


Burn casualties are trauma casualties and may have sustained injuries other than

the thermal trauma. Follow your assessment protocols.

Tactical Field Care

What is the first step?

Stop the burning process


Hot gases and flames cause what airway problems?

Edema of the airway above the vocal cords and can occlude the airway.

What early signs may be present?

Facial burns, singed eyebrows, carbonaceous sputum are all signs of an

inhalation burn


How will circumferential burns of the chest affect a casualty?

By constricting the chest wall. The casualty may suffocate due to an inability to inhale deeply.

In what category are combat casualties with circumferential burns evacuated?

Urgent


Circulation

Ensure all other hemorrhage is controlled.

Assess for circumferential burns.

Obtain vascular access.

Casualties suffering from burns covering greater than 20% of the total body surface area

Immediately begin fluid resuscitation following

"The Rule of Tens"


Avoid placement through burned tissue unless no other site is

available.

An IO catheter should be placed if IV access cannot be established.


Expose the casualty completely and inspect for any other possible

life threatening injuries.

Replace the casualty’s body armor and helmet if there is still significant

risk of enemy contact during tactical field care

or TACEVAC care.


Remove nonadherent

clothing, jewelry and watches,

if not done earlier.


Burn casualties are not able to control their own body temperature effectively.

Hypothermia is possible even in warm weather.

What methods are available to control body temperature in a

combat environment? Answers will vary, but may include:

Blankets, casualty blankets, clothing


Burnt tissue swells.

How does this swelling affect extremities?

Swelling and edema, especially with circumferential

burns of the extremities, can compromise distal

circulation.

Special ConsiderationsSpecial Considerations

Age Respiratory Injury

The leading cause of death in fires is not thermal

injuries but the inhalation of toxic smoke.

The three elements of smoke inhalation are

thermal injury, asphyxiation and

toxin-induced lung injury (delayed).

What degree burn?What degree burn?

Second DegreeSecond Degree

Third Degree BurnsThird Degree Burns

Fourth Degree Fourth Degree

First DegreeFirst Degree

Burn SizeBurn Size

How are scattered burns estimated?Using the surface of the casualty’s palm to represent

1% BSA, the total burn percentage is estimated.

TransportTransport

Which burn casualties get transported as Urgent Surgical?

Inhalation injuries.2nd Degree burns >20%TBSA and 3rd or 4th degree.

Burns to the face, hands, feet, genitalia, perineum or major joints.

Electrical and Chemical Burns.Burn casualty with preexisting illnesses.

Casualties with burns and trauma.Children

PreventionPreventionRemember the Army Combat Shirt (ACS) from your

Introduction to Battlefield Medicine Class?

Designed to provide FR protection to those areas of the body not protected

by body armor

Arms exposed beyond the protection of body armor resulting in full thickness

burnsHands and wrists

protected by FR gloves

Neck and chest well protected by

wearing Improved Body Armor

Check on your Learning…Check on your Learning…

How do circumferential burns complicate casualty care?

Increased chance of compromise to distal circulation due to swelling and edema.

Constrict the chest wall to such a degree that the casualty suffocates from inability to take a deep

breath.

Enabling Learning ObjectiveEnabling Learning Objective

Given a combat casualty suffering from burns,

treat a burn casualtyIAW Prehospital Trauma Life Support

Chapters 13 and 21 and the principles of Tactical Combat Casualty Care.

Burn Wound CareBurn Wound Care

What is the goal of burn wound care?Prevent shock, infection and minimize disfiguration.

What type of dressing is used to cover burns?Dry sterile dressings

Dry sterile sheets or towelsAdditionally, prevent hypothermia!

Burn Wound CareBurn Wound Care

This procedure would be

performed by a medical officer at a Battalion Aid Station or

FMSC, NOT by a 68W.

ManagementManagement

Burn casualties have special fluid resuscitation needs.

Your MO or standing orders may direct morphine for pain management.

If the casualty suffers from only burns,

DO NOT provide antibiotics.

For casualties with burns & penetrating trauma,

antibiotics are indicated.

DO NOTDO NOT

Apply ointments until the casualty has been

evaluated.

Open Blisters

Open eyelids if casualty suffers from thermal burns

Chemical burnsChemical burns

Severe chemical burns to rescuers have occurred because of the inability of the rescuer to identify a chemical source.

Alkali Burn to the Eye

Remove clothing.Brush away dry chemicals.

Remove liquid chemicals by flushing with water.Irrigate eyes.

White PhosphorusWhite Phosphorus

What is special about white phosphorus?A chemical substance that burns when exposed to

oxygen without having to be ignited.

Cover with anything that seals the WP from the air. Maintain the seal until it can be removed.

Inhalation BurnsInhalation Burns

Altered mental status is a sign the brain is not receiving enough oxygen.

If difficulty breathing increases, be prepared

to perform a surgical cricothyroidotomy

Electrical Burns Electrical Burns

Be careful. Turn off the source of electricity before any rescue

attempt is made if possible.

May cause an abnormal heartbeat and loss of pulse.

Consider AED use. Casualties with normal healthy hearts have a great chance for survival.

Electrical BurnsElectrical Burns

Electrical injuries and crush injuries have many similarities.

Ruptured tympanic membranes andfractures to multiple areas of the spine and long

bones are also possible with electrical burn injuries.

Radiation BurnsRadiation Burns

Treatment interventions for radiation casualties are the

same as other types of burns.

The most devastating effects of radiation poisoning in those casualties that survive the

initial exposure, will not appear until a few hours after

the exposure.

Fluid Resuscitation for a Burn CasualtyFluid Resuscitation for a Burn Casualty

Fluid is needed to prevent a burn casualty from going into hypovolemic shock.

How do you think burn casualties lose fluid?

Initiate fluid resuscitation as soon as access is established.

For casualties suffering from only burns, Lactated Ringer’s

is the solution of choice.

If the casualty is in shock due to other injuries, follow combat casualty fluid

resuscitation protocols.(Hextend Bolus x2)

Rule of TensRule of Tens

Estimate the total body surface area (TBSA) burned to the nearest 10%.

Percentage TBSA (to the nearest 10%)

X10 ml per hour for adults weighing 88-176 pounds (40-80 kgs).

Example:

30% TBSA of a 170 pound person was burned

30 X 10 = 300 ml/hour


Calculate the following fluid needs:

A 165 lbs Soldier has burned 27% TBSA

30% (round up) X 10 = 300 ml / hour


For every 25 pounds above 175 pounds, increase the initial rate by 100 ml/hour.

A 200 pound Soldier suffers from burns to approximately 50% TBSA.

50 X 10 = 500 ml/hour

+ 100 ml/hr = 600 ml/hour


Titrate fluids until the urine output is 30-50 ml/hr

(This may require the administration of a urinary catheter- a skill level 2 task)

Overhydration of IV fluids has been a problem with burn casualties.

Massive amounts of IV fluids are no longer the standard of care.


Based on what you have learned: If the tactical situation permits, for which burn

casualty would CPR be a reasonable intervention?

Electrical Burn (Electrocution Casualty)

What type of dressing is used on burns?Dry, sterile dressing.


Based on your previous training, what would be some signs or symptoms that a casualty is

suffering from inhalation burns?

Difficulty breathing (dyspnea)

Coughing, stridor

Breath has "smoky" or "chemical" smell

Black residue in patient's nose and mouth

Nasal or facial hairs are singed

Burns to the head, the face, or the front of the trunk


If the casualty becomes altered and shows signs of increased difficulty breathing what do

you do?Prepare for and provide with a surgical cric.

What is the initial treatment for white phosphorus burns?

Cover the area with water, saline, a wet cloth, or wet mud; keep the area covered with the wet material to

exclude air and to prevent any retained particles from re-igniting and further burning.

SummarySummary

You are called to a small vehicle fire. Your casualty (an 80 kg. male) has second-degree

thermal burns of his anterior trunk, anterior arms, anterior legs & groin. Using the Rule of Nines,

calculate TBSA burned. Anterior trunk=18% Anterior arms=9% Anterior legs=18%

Groin=1%TBSA burned=46%

Calculate the casualty’s fluid resuscitation needs using the Rule of Tens.50 X 10 = 500 ml/hour

SummarySummary

SFC Romero (225 pounds) went to the beach and fell asleep on the sand. When he awoke, his posterior trunk, posterior arms and posterior legs are red and

blistered. He is brought to the BAS for care.What type of burn does this Soldier have?

2nd degree

Calculate the percentage of BSA burned.Posterior trunk= 18% Posterior arms=9% Posterior legs=18%

TBSA burned=45%

Calculate Rule of Tens fluid resuscitation needs.

50 X 10 = 500 ml/hour

+ 200 ml/hr = 700 ml/hour

Questions??Questions??

point of wounding: burn complications

Education