sign in sign up
<<
Home , Electrical burn, Electrical injury, Lightning injury, Radiation burn

Types of Flash – Explosions of natural gas, propane, gasoline & other flammable liquids Intense heat for brief period of time Thermal Flame – Exposure to prolonged, intense heat. Scalds – Caused by hot liquids, water, oil, grease, tar, oil Temperature >156 degrees causes immediate tissue injury Contact – Hot metal/surfaces, plastics, coals Caused by strong acids or alkali substances Chemical Continue to cause damage until agent inactivated Caused by either AC or DC current Electrical Current follows path of least resistance and causes injury in areas other than the contact/entry site Radiological Caused by alpha, beta, or gamma radiation – localized damage to and Cold other tissues due to freezing Exposure Usually occurs in body parts farthest from heart and those with large exposed areas

Scald Burns Chemical Burns

• Caused by hot liquids (eg, water, oil, grease, tar) • Classified as either household • Temperature >156 degrees or industrial agents causes immediate tissue injury • Characterized as: • Accidental scald have – Acid, alkaline, organic irregular borders associated with splash or drip lines • First treatment should be to • Intentional scald burns more irrigate skin with enough water likely to have to dilute chemical clear demarcation of injury – Irrigate acid burns 20 minutes • Scalds accounts for majority – Irrigate alkaline burns 30-45 minutes of thermal injuries to children • Examples of agents • If history does not correlate with physical finds, call – Acid = bathroom cleansers, rust removal products protective services – Alkali = household cleansers-oven & drain, bleach – Organic = creosote (from tar distillation), gasoline/diesel fuel

Electrical Injury/Burns Injury

• Results from passing through body • Primary result is burns causing rapid injury to tissues • May cause fractures or dislocations secondary to blunt force • Classified as: trauma or muscle contractions • High injury usually cause 1. High internal damage (>1000 ), • Extent of high volt damage cannot be judged by skin low voltage examination alone (<1000 volts) • Electricity passing through body 2. Flash burns may injure blood vessels, nerves, secondary to and muscles • High or low volt injury may produce cardiac • Burns from or arrest Full-thickness exit wound to armpit post electrical strike burn injury Electrical Injuries Electrical Injuries

• Damage is dependent on dose, • Wounds typically treated anatomic path, duration of exposure with standard wound care • Consider: • Debridement of any – Potential cardiac arrhythmias charred flesh – activity • May take a significant – Potential renal complications amount of time for associated with: demarcation to occur • – rapid breakdown of damaged muscle tissue • Breakdown products of Urine from a person with rhabdomyolysis showing damaged muscle cells released characteristic brown into bloodstream discoloration as a result of • Myoglobinuria-protein myoglobin myoglobinuria exit site on foot can harm kidneys

Radiation Burns Radiodermatitis (RD)

• Damage to skin caused by • A common side effect during exposure to radiation • Various topical agents • Radiation burns from: have been applied – UV radiation (sun) • However, the efficiency – X-rays of topical agents applied • aka radiodermatitis- on radiotherapy still associated with prolonged Ionizing : uncertain exposure to Large red patches of skin on the back and arm from multiple – High power radio transmitters prolonged (body absorbs radio procedures frequency energy and converts to heat)

Methods for Preventing/Minimizing Advice for Patients for Skin Skin Reactions During Radiation Therapy Reactions During Radiation Therapy

• Moisturization of irradiated area • Lack of general consensus among radiation therapy centers • Use of barrier or corticosteroid creams • Some common advice given to patients include: – Avoid use of metallic-based topical products (eg, zinc oxide creams or • Aloe vera and other lanolin-free deodorants with an aluminum base) - may increase surface dose to skin hydrophilic products often recommended – Avoid alcohol containing products for this purpose – Avoid sun exposure • Objective of treatment for dry – Wear loose-fitting clothing over is to lessen patient irradiated area - prevents friction injuries discomfort by providing moisture to the – Maintain a clean/dry irradiated area affected areas – Avoid extreme temperatures • Treatment of moist desquamation usually – Avoid use of starch-based products – involves the use of hydrocolloid dressings increase the risk of to reduce exposure to external pathogens • No general accord has been reached across radiation therapy centers about and ultimately to prevent infection the treatment of radiation skin toxicities • Additional studies needed Radiation Recall Frostbite

• An inflammatory skin • Categorized with burns due to similar reaction that occurs in a inflammatory responses and ischemic injuries previously irradiated body • Vasoconstriction and endothelial injury with part following drug administration thrombosis and loss of vascular integrity • Factors affecting severity: • Does not appear to be a minimum dose, nor an – Length of exposure established radiotherapy – Temperature dose relationship – Humidity • Poorly understood – Wind chill factor

http://www.podiatrytoday.com/blogged/current-insights-pathophysiology-and-management-frostbite-. Accessed 11/6/15.

Classification of Frostbite Injury Thermal Injury Classifications

• Superficial frostbite includes skin and subq Classified According to Depth – Rewarming results in clear blisters • Deep frostbite includes bone, joint and 1st degree Epidermal damage tendon Superficial – Rewarming results in hemorrhagic blisters • Favorable prognosis include intact and superficial sensation, normal skin color and Partial- •Superficial 2nd (papillary) damage clear blisters Thickness •Deep degree Damage extends into the • Poor prognosis include nonblanching, reticular dermis cyanotic, firm skin and hemorrhagic blisters • No definitive evidence exists for optimal 3rd degree Complete loss of dermis management of blisters Full-Thickness 4th degree Damage to underlying http://www.podiatrytoday.com/blogged/current-insights-pathophysiology-and-management-frostbite-blisters. fascia, muscle, bone Accessed 11/6/15.

Second-Degree Burn First-Degree Superficial Burns Superficial Partial-Thickness • Characteristics – Epidermal damage only Characteristics – Red • Extends into superficial (papillary) dermis – Dry skin • Usually caused by hot liquids – Blanch with pressure • Red, blisters, wet – Painful (48-72 hours) • Painful – Peeling skin • Good blood supply – Examples: • Low risk of infection • Flash injuries • Heals with minimal scarring • 10-14 days • Complete healing 5-10 days without scarring Second-Degree Third-Degree Deep Partial-Thickness Burn Full-Thickness Burns

Characteristics • Destruction of entire epidermis, dermis • Extends into deep (reticular) dermis • May extend to muscle, bone, and joint • Lack of formation (sometimes referred to as Fourth-Degree • Cause is usually flames burn) • Dry, white, or charred skin • Pain is minimal • No residual epidermal cells to repopulate; • High risk for infection therefore no re-epithelialization • Re-epithelialization extremely slow, sometimes requiring months • Area of wound not closed by secondary • Scarring can be severe intention (contraction) requires • Readily converts to a full-thickness burn • Requires extensive debridement & complex • Skin grafting often preferred for long-term function reconstruction of specialized tissues • Usually results in prolonged disability • Caused by immersion scalds, flames, and chemical & high-voltage electrical injuries

Fourth-Degree Treatment Full-Thickness Burns Full-Thickness Burns • Areas not closed by wound contraction will require skin grafting • Often requires extensive excisional debridement • Grafting frequent • Often results in prolonged disability

Characteristics • Functional limitations frequent • Complete destruction of epidermis, dermis, and subcutaneous tissue • Involvement of underlying fascia, muscle, bone, or other structures • White, dry, leathery with absence of pain • High risk for infection • Caused by: immersion scalds, flame burns, chemical & high-voltage electrical injuries • No residual epidermal cells to repopulate; therefore no re-epithelialization

Burn Geographic Zones of Injury Burn Geographic Zone of Coagulation Zone of Stasis • Adjacent to zone of coagulation • Area of greatest heat transfer & damage • Tissue severely metabolically compromised • Irreversible tissue loss • Poor blood flow (stasis) • Devitalized necrotic tissue • Tissue potentially salvageable • May convert to complete tissue loss if prolonged hypotension, infection, or edema Zone of Coagulation Zone of Stasis Burn Geographic Zones Burn Severity Zone of Hyperemia • The American Burn Association has used these • Farthest from the point of direct thermal insult parameters to establish guidelines for the • Injury to the tissues is minimal classification of burn severity – (1) extent, depth, and location of burn injury – (2) age of patient (older considered >50 years) – (3) etiologic agents involved Zone of Hyperemia – (4) presence of inhalation injury – (5) coexisting injuries or preexisting illnesses

American Burn Association Severity Classification Minor Moderate Major

Adult <10% TBSA Adult 10%-20% TBSA Adult >20% TBSA Young or old 5%-10% Young or old >10% Young or old <5% TBSA TBSA TBSA 2%-5% full-thickness <2% full-thickness burn >5% full-thickness burn burn High voltage injury High voltage burn Possible inhalation Known inhalation injury injury

Significant burn to face, Circumferential burn joints, hands, or feet

Other health problems Associated injuries

Total Body Surface Area (TBSA) Rule of Nines Infants/Children TBSA Component for Determining Severity of Wound • Calculation different due to size of head proportionally larger than adults Head 9% • Lund-Browder formula instead of Rule of Nines Each arm 9% • For children over age of one Anterior torso 18% – For each year above one - add 0.5% to each leg and subtract 1% for the head Posterior torso 18% – This formula should be used until the adult rule of Each leg 18% nines values are reached. Genitals/perineum 1% Entire foot 2.5%

• Palm of hand ~ 1% TBSA • Perineum ~ 1% TBSA

Mosby's Medical Dictionary, 8th edition. (2009). Retrieved January 7 2015 2.5% 2.5% from http://medical-dictionary.thefreedictionary.com/rule+of+nines. Mosby's Medical Dictionary, 8th edition. (2009). Retrieved January 7 2015 from http://medical-dictionary.thefreedictionary.com/rule+of+nines. Major Burns Burn Considerations Should be Referred to Burn Center 1. Partial-thickness burns >10% TBSA • Partial-thickness burns heal on their own unless 2. Involve face, hands, feet, genitalia, perineum, or major joints something causes them to convert to full-thickness 3. Third-degree burns in any age group • Infection can cause partial-thickness to become 4. Electrical burns, including full-thickness 5. Chemical burns • Airway integrity primary concern 6. Inhalation injury 7. Preexisting medical conditions that could complicate • Inhalation damage from by-products of combustion management, prolong recovery, or affect mortality and significant cause of mortality 8. Burns and concomitant trauma (such as fractures) in which • Most immediate burn from due to burn injury poses greatest risk of morbidity or mortality carbon monoxide from fire displacing oxygen on 9. Burned children in hospitals without qualified personnel or hemoglobin of RBCs equipment for care of children 10.Patients who require special social, emotional, or rehabilitative intervention

Excerpted from Guidelines for the Operations of Burn Units (pp. 55-62), Resources for Optimal Care of the Injured Patient: 1999, Committee on Trauma, American College of Surgeons.

Emergent or Resuscitative Burn Management Phase Divided into Three Phases • Medical Assessment – Assess for presence of inhalation injury/secure airway 1. Emergent or Resuscitative Phase – Assess size of burn (TBSA) using the “Rule of Nines” 2. Acute Phase (after emergent phase and until – Assess and classify burn depth – Begin fluid (Parkland Burn Formula) wounds are closed) – Maintain body temperature (prevent ) 3. Rehabilitative Phase – to restore function – Achieve cardiopulmonary stability – Establish adequate tissue perfusion and monitor for compartment syndrome – Escharotomies may be necessary to prevent tissue, muscle, and nerve – Debridement of necrotic, dirty, or infected wounds

Parkland Burn Formula Burn Interventions Full-Thickness

• Calculates approximate IV Ringer’s lactate • Proper cleansing needed for first 24 hours • Infection of most concern after airway issues • 4 mL x body weight x %TBSA • Topical antibiotics • ½ first 8 hours, second ½ in next 16 hours – Silver sulfadiazine • In general, monitor and modify according to urine output and vital signs – Mafenide acetate – Neomycin, polymyxin, and bacitracin ointment – Mupirocin ointment – Acetic acid solution – Dakin’s solution – Silver dressings

Burn Triage and Treatment - Thermal Injuries. Retrieved January 7 2015, from U.S. Department of Health & Human Services, Chemical Hazards Emergency Medical Management. http://chemm.nlm.nih.gov/burns.htm. Burn Interventions Elevation of Limbs

• Bandages • Person with a serious burn injury goes into shock, which causes swelling – Protect from infection • Badly burned skin becomes stiff and resists – Reduce body, head, and water vapor loss swelling, leading to increased pressure inside limbs, fingers, or toes that create to tissues – Patient more comfortable – air currents • Keeping injured limb raised reduces pressure to painful help prevent edema-induced ischemia – Assists with positioning for functional healing of limbs/digits – Absorbs drainage from wounds

Surgical Management in Burn Surgical Management in Burns Care Skin Grafting • Escharotomy – surgical cuts in burned tissue allows area to • Full- and partial-thickness burns expand; decrease the • Excision or debridement of burned skin followed by pressure build up from grafting reduces number of days in hospital and usually edema improves function and appearance of burned areas – Pressure build up from swelling can cause due Right hand Note medial and lateral escharotomies to lack of blood flow was allowed to heal on its • Fasciotomy own – Indicated for compartment syndrome Left hand was grafted

Advanced Topical Interventions Exercise for Burns • As burned skin heals, skin around wound contracts (shrinks) toward • Skin grafts center of wound as tissue forms • Flaps in wounded area • Joints must be regularly exercised • Tissue engineered products to prevent scar tissue induced • See Topical Management Section contractures • Contractures often have to be released surgically • Exercising burned limbs can be painful, but increases flexibility and reduces long-term complications • Rehabilitation begun early and continuing throughout healing process ensures greatest flexibility and return to highest level of function Pressure Garments Splinting of Joints

• Hypertrophic scarring – above level of burn/skin • Not fully understood • Keeping pressure on the scar as it forms helps reduce the amount of hypertrophic scarring

Burn References

• Falabella AF, Kirsner, RS. . Boca Raton: Taylor & Francis; 2005;225-237. • American Burn Association: http://www.ameriburn.org/BurnUnitReferral.pdf • burnsurgery.org • Salvo N, Barnes E, van Draanen J, et al. Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of the literature. Curr Oncol. 2010;17:94-112. • Brigham and Women’s Hospital Dept. of Rehab Services. Standard of Care: Inpatient Physical Therapy Management of Patients with Burns. 2008. • Hettiaratchy S, Dziewulski P. ABCs of Burns. BMJ. 2004;328(7453):1427-1429. • Garmel. Mahadevann SV, Gus M, eds. An introduction to clinical . 2nd ed. Cambridge: Cambridge University Press. 2012;216-219.