Objectives

Burns . List burns by the type of causative factors (chemicals, exposures, electrical, etc.) . Identify treatment modalities, including airway Air Methods Corporation management, pain control, and fluid resuscitation Community Based Services Authored by: . Calculate burn percentages, and size estimation Rachel Kubalek, RN, CFRN . List transport modalities and level of care Teather Campbell, RN, CFRN

Burns-Introduction Epidemiology Epidemiology

Epidemiology 013 facts from American Burn Association: 3400 deaths per year are related to Initial management Burn injuries account for an estimated 450,000 fire/burn/and smoke inhalation (nation Treatment annual emergency department (ED) visits per year wide). Associated Injuries 45,000 require hospitalization Nebraska has St Elizabeth burn center that Approximately 60% of these patients are is accredited by the American Burn Center. hospitalized at one of the 125 specialized burn treatment centers in the United States 96.6% of admissions to burn centers from 2003-2012 survive. https://newyorktours.wordpress.com/2014/03/14/the-almost-true-story-of-the- origin-of-st-patricks-day-in-nyc/ Epidemiology Mechanics and Causative Factors Thermal: Flame

With temps > 120 degrees Fahrenheit, it – Thermal Most Common takes only 3 seconds to burn a child's skin • Flame • Scald severely enough to require surgery • Flash • Contact – Chemical – Radiation – Electricity – Lightning

http://www.documentingreality.com/forum/f149/children-burned-hot-coffee-144629/ – Frostbite http://www.documentingreality.com/forum/f149/children-burned-hot- coffee-144629/

http://theawakeneddreamer.com/2011/12/01/when-the-house-burns-down/

Thermal Scald Flash Burns Contact Burns

Second most common burn Liquid Highest in the pediatric population Semi-liquid, (Tar, solvents, water, etc.) Immersion burns involve deeper tissue Objects structures Consider abuse

http://burnssurgery.blogspot.com/2012/01/hand-burns-thermal- cracker_18.html

http://www.medbc.com/annals/review/vol_11/num_3/text/vol11n3p171.htm //www.emsworld.com/article/10839933/burn-care ://chemistrybyscott.org/chemical_burns.htm

http://www barryevans com/injury4 html Electrical Burns Electrical Burns Alternating Current (AC)

Damage is related Entrance Wound Low voltage AC electrocution Amount of tissue conducting the current High resistance of skin transforms electrical energy – three times more dangerous than DC current at Flow of electricity which is: into heat, which produces burns around the the same voltage – Amperage (flow of current) entrance point (dark spot in center of wound) https://www.studyblue.com/notes/note/n/physical-and-chemical- With AC electrocution – Voltage (amount of current) injuries/deck/850913 – Resistance or conductivity of - continuous muscle contractions may occur fluids and tissue AC (Alternating current) has a - since the muscle fibers are stimulated at higher incidence of myocardial between 40 to 110 times per fibrillation than DC (Direct current) second. http://burnssurgery.blogspot.com/2013/10/electrical-contact-burns-spine-exposed.html

http://www.forensicmed.co.uk/wounds/burns/chemical-and-electrical-burns/

Alternating Current (AC) Alternating Current (AC) Example of AC Current

Voltage and type of current – Power lines and electrical transformers Contact electrical – United States and Canada is 110V & some 220V constitute high-voltage energies and involve over burns, – Larger household, industrial applications such as shops, 600 volts – 120-V alternating manufacturing plants, etc., and center pivot irrigation – By definition, high-tension injuries involve current. systems may have as high as 440 V currents of greater than 1000 volts The right knee was the energized side, and the left was ground. – These are contact burns

and are difficult to https://www.osha.gov/SLTC/etools/construction/electrical_incident distinguish from s/burn_examples.html thermal burns. Direct Current Direct Current Exit Wound

High voltage direct current (DC) electrocution Direct current electrocution can also cause Current flows through the body from the tends to cause a single muscle contraction cardiac dysrrhythmias entrance point, until finally exiting where – throwing its victim from the source – dependendent on the phase of the cardiac cycle there is a grounding source – More blunt trauma This foot suffered massive internal injuries, which weren't readily visible, and had to be amputated a few days later

https://www.osha.gov/SLTC/etools/construction/electrical_incidents/burn_examples.html

Arch Burns Thermal Contact Burns Internal Injuries

• This man was near a power box when an electrical Current exited this man at his knees, This worker was energized through a tool he explosion occurred. catching his clothing on fire and burning his was holding. The entrance wound and • Though he did not touch the box upper leg thermal burns from the overheated tool are – electricity arced through the air and entered his body. – The current was drawn to his armpits because noted… perspiration is very conductive

https://www.osha.gov/SLTC/etools/construction/electrical_incidents/burn_examples.html

https://www.osha.gov/SLTC/etools/construction/electrical_incidents/burn_examples.html

https://www osha gov/SLTC/etools/construction/electrical incidents/burn examples html Internal Injuries: Same Hand Involuntary Muscle Contraction Lightning Injuries

Same hand a few days later, when massive This worker fell and grabbed a power line to Second most frequent cause of storm subcutaneous tissue damage had caused catch himself. related deaths. severe swelling (swelling usually peaks 24- – resulting electric shock mummified his first two Usually causes superficial burns, with deep 72 hours after electrical shock) fingers, which had to be removed. tissue penetration from the current. – acute angle of the wrist was caused by burning May cause asystole or fibrillation. of the tendons, which contracted, drawing the hand with them. Short or long term hearing loss or changes. Vision changes or early cataracts.

https://www.osha.gov/SLTC/etools/construction/electrical_incidents/burn_examples.html

Mechanisms of Injury Direct Lightening Strikes Flash Discharge

Lightning injury-5 basic mechanisms Outside, hiking, by a tall object, etc. Struck by a flash discharge or side impact – Direct strike Carrying metal objects from another struck object – Flash discharge (splash) Metal worn in the hair (hairpin) Splash injury also occurs from person to – Contact – Increases the chances of a direct strike compared with a person when several people are standing metal object worn lower on the body – Ground current (step voltage) close together – Associated with high morbidity because they frequently – Blunt trauma involve the head. – May cause hearing loss, cataracts, arthritis, etc. Pathophysiology Pathophysiology Chemical Burns

Lightning injury differs from commercial As lightning follows the shortest route Safety for you and your colleagues high-voltage electric injury between contact points of the human body Injury dependent on the concentration and Brief Duration – it may involve vital structures in its path. the duration of the exposure Direct Current – Almost every organ system is vulnerable. Acid or Alkali High temperature – A wide variety of complications can result from – Irrigate strong acids or alkali exposures for at damage to these organ systems. Sonic waves least 30-60 minutes – Continuous irrigation if eye is exposed to Flash burns chemicals Co-morbid trauma

Chemical Burn- Alkali Chemical Burn-Acid Radiation

Sunburn

Radiation therapy

http://pixshark.com/chemical-burns-in-eye.htm

http://mayhaila.deviantart.com/art/Theatrical-special-effect-burn- 292818760 Sunburn Damage Sun Protection Frostbite

Within 2 hours after UV exposure, damage to As the tissue cools, ice crystals form, cell epidermal skin cells is seen. dehydration follows with cell death Rewarm with 40 degree C water Do not rub or use any friction

http://www.wisn.com/weather/Weather-Blog-Suntastic-Means-Be-Sun- Smart/15461056

Pathophysiology Scene/ER Safety Primary Assessment

Cardiovascular Ensure the burning process is stopped Early & aggressive airway management Decontamination-The causative source is including c-spine protection if necessary Renal removed Metabolism

Immune System

Gastrointestinal https://www.pinterest.com/pin/334181234823059563/ Breathing Circulation

Usually involves the upper airway above the 2 large bore IVs with LR glottis Consensus formula (formerly Parkland burn formula) May have a delayed onset Treat for all injuries Chemical involvement may cause lower Monitor UOP airway damage – Adults->30-50 mls/hr Carbon Monoxide – Pediatrics-1-2 mls/kg/hr

http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148- 769193-367tn.jpg

Lets Calculate a Percentage Fluid Calculation

According to Advanced Burn Life Support(2011) Consensus Formula: – 2 ml per kg X percentage of burn – Give the first half over the first 8 hours from onset of burn – Give the second half over the remaining 16 hours

http://studydroid.com/index.php?page=viewPack&packId=531561 Pediatric Calculation Pediatric Fluid Calculation Pediatric Urinary Output

9 month old,10 kg patient brought to ER Per Advanced Burn Life Support (ABLS): The fluid infusion rate should be increased or Z Children: 2-4 ml LR x Kg body weight x % BSA burn – second and third degree burns: Z Half administered in the first 8 hours post burn. decreased by one-third • to chest, abdomen, scrotal area, upper right arm and Z The remaining half the next 16 hours Z if the urinary output falls below or exceeds the palm of right hand. desired level by more than one-third for two to three hours. (Children <30 kg UOP goal = 1ml/kg/hr)

http://www.aobbangladesh.org/node/207

http://www.healthofchildren.com/I-K/Intravenous-Rehydration.html http://emedicine.medscape.com/article/769193-overview http://admalmenevo.ru/?q=Urine+Output+Calculator

Infant Fluid Calculation Pediatric Fluid Calculation (cont.) Disability

Infants < 12 months and young children: 2 ml per kg X % of burn. Neuro assessment before and after sedation Fluid with 5% dextrose at a maintenance Pt weight is 10kg. and paralytics. rate in addition to the resuscitation fluid 2 ml X 10 X 20.5= 420 ml over 24 hours. Assess for circumferential burns. Monitor noted above. 210 ml is given in the first 8 hours from the pulses, motor and sensation distal to the onset of burn (run at 26 ml/hr) injury. Monitor for compartment syndrome

» ABLS 2011 Pain Management Pain Management (cont.) Exposure After the burning process is stopped, remove wet clothes, Aggressively treat and manage pain blankets, etc Cover with clean dry sheets or blankets (They do not need If the patient is not intubated, administer IV to be sterile). Avoid wet dressings as they can cause opioids in small boluses and titrate to effect. hypothermia. Monitor closely for respiratory depression. Maintain temperature, avoid hypothermia Anxiolytics such as Ativan may be necessary. Consider intubation if pain control is inadequate.

https://ispub com/IJS/21/2/5354

Secondary Survey If in Doubt Special Considerations

Check for associated trauma. Pediatric Population CALL YOUR BURN CENTER Estimate burn size Pt䇻s palm=approx. 1% of burned area

http://www.jsonline.com/news/health/burn-center- http://www.dailymail.co.uk/news/article-2389972/Three-month-old-baby-boy- jobs-stressful-rewarding-4s6ov1b-169067626.html suffers-horrifying-burns-spontaneously-bursting-flames-fourth-time.html //www.ambonsall.com/NSWResusBurnsFluids.htm http://www.raems.com/articles/parkland.htm Brand Burns Cigarette Burns Cigarette Burns

The imprint of a hot object: Cigarette burns are circular, Cigarette burns usually are third-degree, deep, and 8 to 10 mm in diameter, and of uniform depth relatively painless: – Curling iron or flat iron – These burns may be difficult to distinguish from impetigo – Occur on the face or on the dorsa of the hands or feet. – But the latter involves superficial skin layers and occurs – Impetigo heals cleanly with antibiotic therapy in crops – Whereas cigarette burns heal slowly and leave scars

http://www.thesun.co.uk/sol/homepage/news/scottishnews/2757604/ Tot-Kayla-Murray-gets-440-degree-burns-from-hair-straighteners.html http://jeffreysterlingmd.com/tag/burn/ http://www.abusewatch.net/child_medimage.php

Cigarette vs. Impetigo Immersion burns Transfer Criteria

Immersion burns usually are seen on the Transfer to a burn center: buttocks or legs, or in a stocking or glove – Partial thickness burns > 10% TBSA distribution on the extremities – Burns to face, hands, feet genitals, perineum or Uniform depth, with a sharp line of joints demarcation between burned and normal – Any 3rd degree burns skin – Electrical http://www.doctorshangout.com/forum/topics/possible-child-abuse – Chemical – Inhalation

http://bestpractice.bmj.com/best-practice/monograph/476/resources/images.html Summary Questions? References

. Stop the burning process WWW.CDC.com Trauma Nursing Core Course, 7th edition, copyright 2014 by . Aggressive airway management ENA . Adequate fluid resuscitation Wendling, P., think plastic wrap as wound dressing for thermal burns, ACEP News, Elsevier Global Medical News . Maintain warmth after exposure American Burn Association 2013 .Analgesia . Burns are distracting, look for other injuries