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Burn Injury
May 2009 CE
Condell Medical Center EMS System
Prepared by: FF/PM Michael Mounts
Lake Forest Fire Department
Reviewed/revised by: Sharon Hopkins, RN, BSN, EMTEMT-P
Objectives
Identify the different functions of the
integumentary system (skin)
Identify the different layers of the
integumentary system and how they are
affected by each burn classification.
Identify Total Body Surface Area (TBSA) of
burn following the “Rule of Nines” method.
Identify the different classifications of burns
when given a photo or signs & symptoms of
that injury.
Identify the different types of burn injury, i.e.
thermal, chemical, electrical, & inhalation.
Objectives cont.
Identify abuse/neglect cases
Identify assessment techniques
Identify Region X SOP for burn injuries
Identify fluid resuscitation guidelines
(Parkland Formula)
Review proper wound care with dressing
application for burns
Return demonstrate use of the IO drill for
the adult and pediatric patients
Burns
Burn Incidence
More than 1 million burn injuries per year
45,000 hospitalizations per year
Half go to one of the 125 specialized burn centers
The other half go to the nations 5000 other
hospitals
4500 fire and burn deaths per year
3750 burns from fire
750 (burns from MVC, electrical, chemical,
scald, other)
Severity of Burn
Severity of burn determined by depth, size,
and location
Average TBSA (Total Body Surface Area)
admitted to a burn center is 14%
Overall percentage of the TBSA is on the
decline
About 6% of Burn Center
Admissions do not survive
Pediatric Problems
35% of all burn injuries occur in children
85% of pediatric burns are toddler aged
From one to three years of age
2,500 children die from thermal injury
10,000 suffer severe permanent disability
Second leading cause of accidental death in
children
Seasonal Injuries
Summer (BBQ,
automobiles)
Fall (burning leaves
& brush, turkey
fryers)
Winter (house fire
& alternative
heating)
Spring (similar to
fall)
Function of the Skin
Skin is the largest, most important organ
16% of total body weight
Function
Protection
Sensation
Temperature regulation
Aka: Integumentary system
Body Temperature Regulation
Loss of the integrity
of the skin results in
the loss of
evaporative & heat
barriers
Body heat is lost by
Convection
Conduction
Radiation
Anatomy & Physiology of Skin
Skin
Layers
Epidermis
Social function – visible part of body
Outmost, avascular layer of dead cells
Helps protect body from bacteria &
toxins from the environment
Prevents excessive water loss
Sebum – waxy surface lubricant
Neurosensory function – touch, pain,
pressure, sensation
A & P of Skin cont’d
Dermis
Controls body temperature & provides
flexibility
Upper layer (papillary layer)
Loose connective tissue, capillaries and
nerves
Lower layer (reticular layer)
Integrates dermis with subcutaneous layer
Blood vessels, nerve endings for touch & pain,
hair follicles, & glands
Sebaceous & sudoriferous glands
Burns into dermis are considered significant
Healing occurs if the dermal layer is present
A & P of Skin cont’d
Subcutaneous
layer
Adipose tissue
• Tissue that contains stored fat
Heat retention
Normal Skin Cross-section
Damaged skin
cross--section
cross
Note
differences
between
levels of
injury
Depth Determination/Severity
Burning
substance
Temperature
Duration of
exposure
Location of body
Age of the patient
Initial care of the
burn provided
Adult Rule of Nines
Infant Rule of Nines
Notice the larger %
for their head
18% for the entire
anterior thorax
including chest and
abdomen
Posterior area often
broken into 13% for
back and 2.5% for
each buttock cheek
Rule of Palms
An alternate system for approximating the
extent of the burn
Especially helpful in small, local burns
The patient’s palm minus fingers represents
approximately 1% of their total body
surface area
Can be used for all persons; all ages
Must use the patient’s palm, not yours
Need to visualize the palmar surface and
apply that to the injured area
Patient’s burn area is
re-calculated at burn
unit using this chart
More accurate than
Rule of Nines
*Note –
Patient’s palm = 1%
Burn Classifications
Superficial
First Degree
Partial Thickness
Second Degree
Third Degree
Full Thickness
Revised Burn Nomenclature
Superficial Burns
Involves only the epidermis
Think sunburn:
Red
Dry
Often painful
Heals is less than one week without scarring
Superficial Burns cont.
Red,
dry skin
Handprint showing
that he won’t be
modeling anytime
soon
Partial Thickness Burns
Involves entire epidermis
and part of the dermis
Skin is red, blistered,
swollen and wet
PAINFUL!!
Superficial heals 1010-12
days without scarring
Partial Thickness Burns cont.
Red, wet, blistering, peeling, skin
PAINFUL!
Partial
Thickness
Burns
Boiling water
Hot glue gun 1450C
( 3180F)
Scald burn
Full Thickness Burns
Involves entire
epidermis and dermis
May extend into
underlying structures
Wounds are DRY,
charred, white, leathery,
or waxy
May also see coagulated
blood vessels
Full Thickness Burns cont.
White, waxy appearance
Does not blanch to pressure
Non Burned
Area
PATIENTS may STILL HAVE
PAIN!!
BECAUSE...
Third degree burns are usually
surrounded by first and second
degree burns!
Eschar
Dead skin
Leathery
Dangerous potentials:
Compartment
syndrome
Chest restriction
Subeschar edema
Patient will need
grafting
Local Tissue Response to Burn
Injury
Jackson’s Theory of Thermal Wounds
3-Dimensional model showing burn
depth and TBSA burned
3 Zones of Injury
Zone of Coagulation
Zone of Stasis
Zone of Hyperemia
Jackson’s Thermal Wound Theory
Zone of coagulation
Area nearest the burn
Ruptured cell membranes, clotted blood and
thrombosed vessels
Zone of stasis
Area surrounding zone of coagulation
Inflammation, decreased blood flow
Zone of hyperemia
Peripheral area of burn
Limited inflammation, increased blood flow
Types of Burn Injury
Thermal
Chemical
Electrical
Inhalation
Note: Following each burn type,
there are pictures showing examples.
Some pictures are quite graphic!
Types of Burn Injury cont.
Thermal - Damage to tissues from exposure
to heat and/or flame
Scald
Flame
Thermal contact
2 day old scald by hot radiator fluid
What would you do in the field for the
blister?
Leave it intact – it acts as a protective
dressing
Patient upon arrival
on unit
With torso burns
and possible airway
involvement,
patient mortality is
high
What concerns
would EMS have in
the field?
Nonburned area
Scald Burn – Partial thickness on back and arms
Full thickness from waist down
Deep fryer
pulled off
counter
Full thickness
*Note swelling
to face
Flame Burn
Full & Partial thickness
Full thickness with partial around edge. Deep partial
thickness may heal in 2-3 months with severe scarring.
Thumb and fingers are full thickness
Full thickness – only area not burned is under thigh
(pink area)
*Note – Hand burns at top of picture
Full thickness to abdomen inner thigh and breast
Tar Burns
Treat tar burns as thermal burns
Immediately cool the burn with large
amounts of water
Due to the extremely high temperatures and
the solidifying of the tar on contact, the
burns are usually very severe
Neosporin ointment or sunflower oil are
dispersing agents that help with removal of
tar from burns
This would be performed in the ED
Chemical Burns
Often occupational
May occur secondary
to assault
Acid/alkali or
petroleum distillate
Severity depends upon
Agent &
concentration
Volume
Duration of
exposure
Treatment Principles for Chemical
Burns
Alkalis should be flushed for a minimum of
15 minutes
Acid exposures should be flushed for a
minimum of 5 minutes
Unknown exposures should be flushed for
20 minutes
When flushing eyes, turn the head to the
side, raise the eyelid off the eyeball to flush
contents trapped under the lid
Do not delay transport to continue flushing
Chemical burn to arms, torso & legs
*Note – NOT burned around pectoral & belly
Non-burned
areas
Chemical burn – burning to legs & feet around
laces of work boot (same pt as previous slide)
Chemical burn to thigh
*Note drip marks near the top
Battery acid poured on car seat –
prolonged contact increases the injury
Sources Electrical Burn
Low
voltage injury
High voltage injury
Lightning injury
Electrical burn of mouth
Electrical Burn Injuries
Entrance
and Exit wounds can differ
greatly in appearance and severity
Most of the damage is done upon exit
of the energy and within the tissues it
passes
The next three slides are of the same
patient.
Electrical entry wound
Partial to full thickness
*Note – electrical burns between entry and exit
wound, work from the inside to the outside
Electrical exit
wound
Lightning Strikes
If
you hear it, clear it!
If you see it, flee it!
The threat of lightning strikes can remain up to 30
minutes after last clap of thunder is heard
Electricity forces in the patient have dissipated by
the time rescuers reach the victim
Arrested patients have a good chance of survival if
rapid ALS is applied
Immediate CPR started
Defibrillation for ventricular fibrillation
Airway control
Lightning Strikes
Strike usually causes asystole
Property of automaticity usually restarts a
rhythm
VF develops secondarily to the initial
respiratory arrest if not corrected fast
enough
If not arrested at the initial strike,
unlikely to arrest later
Put attention to the arrested patients first
External wounds, if any, treated as thermal
burns
Pathway of Travel Through the
Body of a Lightning Strike
Least resistance
Nerves (designed to carry electrical signals)
Blood vessels (filled with water & electrolytes)
Muscle
Mucous membranes (moist)
Intermediate resistance
Skin
Most resistance
Tendons, fat, bone
Inhalation Injury
Mechanism of
injury
Carbon monoxide
Thermal injury
(injury above the
glottis)
Chemical injury
(injury below the
glottis)
Grade 4 Inhalation burn of trachea to R and L bronchi.
*Note – Inhalation burns are rated 1 thru 4 (4 is worst)
Abuse/Neglect
Delay in care
Inconsistent story
Distribution does
not fit story
Other signs of
abuse
All pediatric burns
require
psychosocial
evaluation
Uninjured
skin - pt
African
Full thickness dunk in hot water bathtub American
*Note – NOT burned behind knees or above waist
Behind knees not burned because child pulled his legs up.
If child had stepped into tub, bottoms of feet could
not have been burned this severely. Child was
held/dunked by an adult. (same pt.)
Foley placed quickly due to swelling. (same pt.)
Initial Assessment
Stop the burning
process as
assessment is
started
Airway/c
Airway/c--spine
immobilization
Breathing
Circulation
Don’t forget ABC’s !!!
Intubation can be difficult due to tissue
swelling which worsens with time.
Major swelling to face after burn
* Note - ETT placement is measured by gums or
teeth, NOT lip line
*Note – ETT tied and not taped, tape will not stick to
burn area and can cause more injury to tissue
Initial Evaluation - Being Suspicious
of Abuse/Neglect
Events leading to
injury
Medical history
Does distribution fit
injury
Does it look how
they say it
happened?
Second Step of Assessment
Focused History & Physical Exam
Determine extent
Rule of Nines
Minimize edema
Cooling
Elevation of extremity
Fluid resuscitation
20 ml/kg adult and
pediatric patients if
fluids are needed
Region X SOP BURNS, ADULT
Remove patient from burn source
Routine Trauma Care
Assess particularly for airway and / or circulatory
compromise
⇓
Evaluate depth of burn and estimate extent using Rule of
Nines.
⇓
MORPHINE SULFATE 2 mg IVP slowly over 2 minutes
May repeat every 2 minutes as needed
to a maximum total of 10 mg
⇓
FURTHER CARE DEPENDENT ON MECHANISM OF
BURN:
SOP
⇓
⇓
Page 36
⇓
ELECTRICAL BURNS - Adult
Ensure rescuer safety
Remove from source
• Immobilize
• Assess for dysrhythmia
• Identify and document any entrance and
exit wounds
• Assess neurovascular status of affected
part
• Cover wounds with dry sterile dressings
SOP Page 36
⇓
CHEMICAL BURNS - Adult
•
•
•
•
•
•
•
Refer to Haz / Mat protocol
If powdered chemical, brush away excess
Remove clothing if possible
Flush burn area with sterile water or saline
•IF EYE INVOLVEMENT
Rapid visual acuity
Remove contact lens and irrigate with saline or
sterile water continuously. DO NOT
CONTAMINATE THE UNINJURED EYE
WITH EYE IRRIGATION
• SOP Page 36
⇓
INHALATION BURNS - Adult
Note presence of wheezing, hoarseness,
stridor, carbonaceous sputum, singed nasal
hair.
May include CO poisoning, heat or smoke
inhalation
High flow oxygen
Consider advanced airway
SOP Page 36
⇓
THERMAL BURNS - Adult
•Superficial (1st degree)
Cool burned area with water or saline
<20% body surface involved, apply sterile saline soaked
dressings.
DO NOT OVER COOL major burns or apply ice directly to
burned areas.
•Partial or Full thickness (2nd or 3rd degree)
Wear sterile gloves / mask while burn areas exposed
Cover burn wound with DRY sterile dressings
Place patient on clean sheet on stretcher, cover patient with
dry clean sheets and blanket.
NOTE: Use of ice for cooling is absolutely
contraindicated.
SOP Page 36
Region X SOP for Pediatric Burns
Follow the same format for the adult patient
with burns
Protect all patients from overover-exposure to
cooling
Need to prevent hypothermia
Assess for potential of child abuse
Contact Medical Control for pain control
Monitor Fluid Resuscitation
Patients may require more
fluid with prepre-existing
dehydration, inhalation
injury, & full thickness
burns
Parkland formula used as
a a guideline in the
hospital
Foley catheter inserted to
measure output
Goal for urine output is
30--50cc/hour
30
Parkland Formula
Parkland formula is used as a guide to
determine proper fluid resuscitation
4 ml of LR /kg/% of TBSA = total fluid
requirement in first 24hrs.
½ over first 8hrs.
Other ½ over the next 16 hours
VERY IMPORTANT to accurately record
fluids given in the field
Example:
A patient with 56% TBSA burned, weighing
110kg
[4] x [14] x [110]
Total fluid = 6160 mL in first 24 hours
3080 mL given over 8 hours = 385mL/hr
385mL/hr
3080 mL given over 16 hours = 193mL/hr
193mL/hr
Importance of Fluid Resuscitation
Inadequate fluid resuscitation can lead to
renal failure and death
Lactated Ringer's solution (LR) - is a
solution that is isotonic with blood and
intended for intravenous administration.
administration.
For more info…
http://en.wikipedia.org/wiki/Lactated_Rin
ger%27s_solution
Poor urine output to good output
Massive protein and plasma loss all the way to near normal urine.
*Note - your normal urine should be clear with proper fluid intake
You can tell how bad pt condition is by what
systems are affected
Sample Transfer Criteria: Loyola
10% or more TBSA
partial thickness burn
Any full thickness
burn
Burns to feet, hands,
face & perineum
Circumfrential burns
Concurrent trauma
Chemical burns
Inhalation burns
Burn injury with prepreexisting medical
conditions
Burned children in
hospitals without
qualified personnel or
equipment qualified to
care for children
Burns requiring extensive
rehabilitation
Transfer Mode
Determined by
transferring MD and
accepting MD
Patients may be
accepted directly from
the scene or by a
transferring hospital
Remember why we’re here…
More Info
The following photos are of some advanced
care equipment and techniques
Many of the photos are quite graphic
Burns often evolve over time
What is initially seen in the field evolves
in the ED and over the early first days
after the initial insult
Doppler being used to find a pedal pulse
Flash burn to face – eye drops being
instilled
Escharotomy
Surgical approach
to prevent/treat
compartment
syndrome
Incision extends
through entire
depth of skin
Full thickness with chest and abdominal
escharotomy
Escharotomy of right leg
Bilateral escharotomy
Infant arm escharotomy
Debridement & Grafting
Surgical removal of dead/infected tissue.
May have grafting procedure after
debridement
Initial Wound Care of Burns
Keep patient warm
Initial cooling
methods may cool
patient too much
No wet dressings or
ice for partial
thickness or full
thickness burns
ED may consult with a
burn center
Principles of Dressing Application
When dressings are applied, skin should not be
touching skin
Place gauze between fingers or toes before
wrapping the extremity.
Begin wrapping distally and work upwards
Never pull tight on the dressings
Anticipate injuries to swell
If saline dressings are used, wring out the dressing
so it is not dripping
Use the wetwet-to
to--dry technique
Place dry dressings over the moist dressing
Dressings
No creams are applied
Sterile saline would be solution of choice if one is
needed
Saline is isotonic
Accepted cleansing agent used in the hospital
Review proper burn / wound injury care
Types and sizes of dressings
Temperature regulation
nd and 3rd degree burns
Dry dressings for 2
Keep patient warm
• Avoid hypothermia
– Burned skin loses ability to retain heat
Scenarios
The following scenarios will require finding
out the burn severity and percentage of burn
for each pt.
Use the Rule of Nine’s
Percent of burn estimation should be
within +/+/- 4%
Scenario #1
Called for a 10 year old girl that spilled hot
chocolate on chest and lap. Upon arrival pt
complains of severe pain and this is what is
visually noted…
Same pt, side view
Scenario #1
What classification of burn(s) is it?
What is the percent of burn area?
Approx. 14 - 16%
How do you call it in?
Full thickness (3rd) with partial (2nd) on edges
Be descriptive as to how the burn happened and
how it appears
What is your care?
Remember to remove diapers from
infants as they can retain the hot fluids
and continue the burning process
Scenario #2
Called for a 19 year old that was burned by
a backyard firepit. Upon arrival pt
complains of pain/tightness in left hand and
leg.
Scenario #2
What classification of burn(s) is it?
2nd and 3rd to leg
1st and 2nd to forearm, at least 1st to hand
What is the percent of burn area?
How do you call it in?
Approx. 13%
Note the areas of blistering and soot. Those
areas may be hard to determine degree and %
of burn.
What is your care?
Scenario #3
Call for a 4 year old that put water in a bath
tub that was too hot. Mother states that he
was sitting in tub and running water by
himself. Pt says his legs “kind of hurt”.
Uninjured
Skin
Scenario #3
What classification of burn(s) is it?
What is the percent of burn area?
Approx. 42% (buttocks, both legs and
perineum)
How do you call it in?
3rd degree
Note degree, amount, cause and the fact that it
is circumferential. Also, pass on suspicions of
abuse based on story.
What is your care?
Questions on burns ?
Intraosseous Needle Insertion
Indications
Shock, arrest, impending arrest
Unconscious/unresponsive to verbal
stimuli
2 unsuccessful IV attempts or 90 second
duration
Adult needle = weight over 40 kg (88#)
Pediatric needle = weight 3 – 39 kg (88#)
IO Contraindications
Fracture of the tibia or femur
Infection at the insertion site
Previous orthopedic procedure (knee
replacement; previous IO insertion within
48 hours)
Pre
Pre--existing medical condition
Inability to locate landmarks
Excessive tissue at the site
Obese leg – hold leg up by the foot and
allow tissue to fall away if possible
IO Equipment
Driver with needle
attached
Needle length
for amount of
tissue to
penetrate
IO Insertion Steps
BSI precautions
Prepare equipment
IV bag and tubing, start pak, IO needle,
IO drill, EZEZ-connect tubing, syringe with
normal saline, arm band
Prepare site
Insert needle at 900 angle
Remove driver from needle set
Remove stylet (rotate counterclockwise)
Connect primed EZEZ-connect tubing
Use the syringe to aspirate then flush with
NS
Remove syringe from EZ connect tubing
and attach IV tubing
Apply pressure to the IV bag
Secure IO needle and tubing
Apply wristband to same side wrist
If IO insertion missed, still apply
wristband to indicate a missed attempt
Confirmation of IO Insertion
Needle stands up on own
Ability to aspirate bone marrow
Easy flushing without resistance
Good IV flow
Remember to use pressure bag around IV
tubing
Additional Information
Poison Control Center
1-800
800--222222-1222
IAFF Burn Foundation
Educational materials
http://burn.iaff.org
Bibliography
Original PowerPoints from…
Burns CE Region 8 Sept. 2007
Laurie Herbert RN, BSN
Burn Injury
Kathy G. Supple RN, ACNP, CCRN
Loyola Burn Nurse Practitioner
Bledsoe, B., Porter, R., Cherry, R. Essentials of Paramedic
Care. 3rd Edition. Brady. 2009.
Campbell, J. Basic Trauma Life Support, 5th Edition,
Brady. 2004
International Association of Fire Fighters Burn
Foundation. First Responder Guide to Burn Injury
Assessment and Treatment. 2007.
Region X Standard Operating Procedures, March 2007
Amended version May 1, 2008
www.lightningsafety.noaa.gov/outdoors.htm