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Objectives. Burn Assessment and Management. Questions Regarding the Case Study. Case Study. Patient Assessment. Patient Assessment

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2005 EMT-Intermediate Curriculum Bridge Course

Burn Assessment and

Management

2005 EMT-Intermediate Curriculum Bridge Course

Objectives

• Discuss the mechanisms and

complications of a thermal burn, electrical burn and an inhalation burn • Explain the factors to consider when

determining the severity of a burn

2005 EMT-Intermediate Curriculum Bridge Course

Case Study

• You are called to an elementary school for a burn injury.

• You are told that a staff member lost their grip on a vat of hot oil and spilled it on their arms.

• The patient is in the school nurse’s office.

2005 EMT-Intermediate Curriculum Bridge Course

Questions Regarding the Case

Study

• How severe is this mechanism of injury? • Will you expect to find any compromise

to airway, breathing or circulation during your initial assessment?

• How severe will you expect the burn to be?

Patient Assessment

• The patient is awake, conscious and tearful • She is breathing

normally but appears to be in significant pain

• Her burns appear isolated to her hands and lower arms.

Patient Assessment

• Vital signs – HR is 96 – RR is 16 – BP is 140/88 • Patient History

– She is 55 years old – History of hypertension

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2005 EMT-Intermediate Curriculum Bridge Course

More Questions

• Is this a critical burn?

– Rationale, please

• Treatments?

– Oxygen? – IV size and rate? – Pain control? – Trauma entry?

2005 EMT-Intermediate Curriculum Bridge Course

Mechanisms of Thermal Burns

2005 EMT-Intermediate Curriculum Bridge Course

Phases of a Burn Injury

• Emergent Phase

• Fluid Shift Phase • Hypermetabolic Phase • Resolution Phase

2005 EMT-Intermediate Curriculum Bridge Course

Complications of Thermal Burns

• Infection • Eschar formation

Burn Assessment

Burn Assessment

• Scene Assessment – Safety First! – Mechanism of Injury • Chemicals • Enclosed space? • Other trauma? • Intentional? • Initial Assessment – Airway compromise • Now? • Potential for this

later? – Breathing • Associated with cough – Circulation • Signs of shock

(3)

2005 EMT-Intermediate Curriculum Bridge Course

Potentially Critical Findings

• Hoarseness • Adventitious airway sounds • Soot in nose or on tongue • Singed hair • Facial edema • Dysphagia • Dysphasia • Adventitious breath sounds • Significant dyspnea • Altered level of consciousness 2005 EMT-Intermediate Curriculum Bridge Course

Focused Physical Assessment

• Signs of trauma – Musculoskeletal injuries – Isolated injuries – Evidence of abuse – Signs of shock 2005 EMT-Intermediate Curriculum Bridge Course

Focused Physical: Burn

Assessment

• Appearance – Description and location(s) • Redness • Blisters • Edema • Weeping of fluid • Charring • Sloughing of skin 2005 EMT-Intermediate Curriculum Bridge Course

Focused Physical Assessment

Determining the Severity of a Burn • Depth of the burn

• Percentage of the body burned • Location of the burn

• Other factors

Determining Burn Severity

• Depth

– Classification

• Superficial • Partial-thickness • Full-thickness What is the depth

of her burn?

Determining Burn Severity

• Body surface area – Rule of Nines • Adult • Pediatric – Rule of Palms • Small burns • Use of the patient’s palm

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2005 EMT-Intermediate Curriculum Bridge Course

What is the % of BSA Involved in

Our Patient?

2005 EMT-Intermediate Curriculum Bridge Course

Determining Burn Severity

• Other factors

– Burn location

• Hands, feet, genitalia

– Age

– Pre-existing medical conditions – Medications

– Presence of multi-systems trauma – Inhalation injury

2005 EMT-Intermediate Curriculum Bridge Course

Back to the Patient

• Is this a critical burn? • Will you still stick to

your original treatment plan? – Oxygen rate – IV – Pain medications – Trauma entry 2005 EMT-Intermediate Curriculum Bridge Course

Complications From a

Significant Burn Injury

Complications

• Fluid loss – Weeping of wounds – Hypothermia potential – Electrolyte loss – Hypovolemia

• Signs of shock indicate that there is another serious injury present

• Shock resulting from a burn will typically occur hours after the insult

Complications

• Systemic acidosis

– From tissue death

• Hypoxia • Infection • Organ failure • Eschar

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2005 EMT-Intermediate Curriculum Bridge Course

General Management of Burns

• Airway and ventilatory support

– Early recognition of potential airway compromise

• ALS intercept is critical for early advanced airway management

• Consider transport to a trauma facility if the MOI and/or initial patient presentation indicates a severe inhalation injury

2005 EMT-Intermediate Curriculum Bridge Course

General Management of Burns

• Circulatory Support

– IV therapy

• Parkland formula

– Specific IV rate for the first 24 hours of a burn

• Fluid resuscitation if signs of shock • Placement for the administration of pain

medications

2005 EMT-Intermediate Curriculum Bridge Course

Parkland Burn Formula

• Fluids for first 8 hrs

4ml x % Burn area X pt. Wt. In kg = Total

2 mL

4 x 20% burn X 70 kg / 2 = 2800 ml

2005 EMT-Intermediate Curriculum Bridge Course

Emergency Care - Thermal

Burns

• Stop the burning • Assess breathing

• Look for signs of airway injury, soot, burnt nasal hair, facial burns

• Humidified oxygen

• Complete initial assessment • Treat for shock

Emergency Care - Thermal

Burns

• Evaluate burns by depth, extent, and severity

• Remove clothing and jewelry • Separate fingers or toes with sterile

gauze pads

• Wrap in dry sterile dressing

General Management of Burns

• Medications for pain management

– Morphine sulfate

• Potent analgesic

• Suppresses the conscious awareness of pain in the brain • Reduces anxiety

– Ketorolac

• NSAID

• Suppresses the pain response in the cell membrane • Works well with acute, severe pain

– Nalbuphine

• Similar properties as morphine

• Similar effects: sedation, lowered awareness of pain • Less side effects as morphine

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2005 EMT-Intermediate Curriculum Bridge Course

Specific Burn Profiles

2005 EMT-Intermediate Curriculum Bridge Course

Another Case Study

You respond to the scene of a house fire with a person trapped. After you arrive on scene you see firefighters at the front door

of the house. 2005 EMT-Intermediate Curriculum Bridge Course 2005 EMT-Intermediate Curriculum Bridge Course

Patient Assessment

• Patient is approximately 45 years old and is unconscious/unresponsive to painful stimuli. • He has heavy soot deposits on his face and in

his nose. He is not breathing.

• Firefighters tell you that the patient was not moving when they found him on his bed. • The patient has no thermal burns on his

body.

Mechanisms of Inhalation Injuries

• Superheated air

– Mechanism similar to a thermal burn – Mucous membranes will intensify the

burn

– Fluid shifts may cause progressive airway obstruction

• Chemical burns

Inhalation Injuries Severity

• Product of combustion

• Duration of exposure • Confined space

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2005 EMT-Intermediate Curriculum Bridge Course

Inhalation Injuries

• Edema can be progressive • May appear mild at first

• Symptoms may not appear for hours

2005 EMT-Intermediate Curriculum Bridge Course

Progressive Edema

2005 EMT-Intermediate Curriculum Bridge Course

Signs and Symptoms of Upper

Airway Injury

• Singed nasal hairs • Facial burns • Burned specks of carbon in the sputum • Sooty or smoky smell on breath

• You may see burns of the oral mucosa

2005 EMT-Intermediate Curriculum Bridge Course

Upper Airway

– Restriction of chest wall movement – Restlessness – Chest tightness – Stridor – Wheezing – Difficulty in swallowing – Hoarseness – Coughing – Cyanosis

Signs of Respiratory Distress

Inhalation of Noxious Fumes

• Mucosa in lungs swell and break • Fluid leaks into alveolar space • Cilia is damaged • Mucus builds up • Airway is plugged • Oxygen exchange is reduced

Inhalation Assessment Tip

• Isolated burns do not alter levels of

consciousness

• If unconscious assume carbon monoxide

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2005 EMT-Intermediate Curriculum Bridge Course

Electrical Burns

• Contact Burns (when the current is

most intense at the entrance and exit sites)

• Flash Burns

• Arcing injuries (when current jumps from one surface to another)

2005 EMT-Intermediate Curriculum Bridge Course

2005 EMT-Intermediate Curriculum Bridge Course

Severity of Electrical Shock

• Voltage and amperage of the current

(amperage kills)

• Alternating or Direct current

• Amount of time the patient is exposed • Amount of moisture on the patient

2005 EMT-Intermediate Curriculum Bridge Course

Severity of Electrical Shock

• Amount of body surface in contact with

water

• Amount of insulation worn by the patient

• Area of the body through which the current passes

Signs and Symptoms of

Electrocution

• Dazed or confused

• Obvious and severe burns on the skin • Unconsciousness

• Weak, irregular, or no pulse

• Shallow, irregular, or absent breathing • Multiple severe fractures due to intense

muscle contractions

Electrical burns are more severe at the point of exit. This child shows exit burns from the face.

Point of entry could not be determined.

(9)

2005 EMT-Intermediate Curriculum Bridge Course 2005 EMT-Intermediate Curriculum Bridge Course 2005 EMT-Intermediate Curriculum Bridge Course 2005 EMT-Intermediate Curriculum Bridge Course

Emergency Care - Electrical

Burns

• Assure your safety first • Provide airway care • Provide CPR as needed • Care for shock

• Care for spinal injuries, head injuries, and severe fractures

Emergency Care - Electrical

Burns

• Evaluate electrical burns, looking for at least two external burn sites, entrance and exit

• Cool the burn, remove clothing • Apply sterile dressing

• Transport, be prepared for cardiac or respiratory arrest

Summary

• Multiple factors should be evaluated when determining the severity of a burn

• Burn injuries will generate inflammation and swelling

– Severe injuries will result in severe swelling – Consider this complication when making treatment

and transport decisions

• Emotional care is also a necessary component in the EMT-I’s treatment plan

References

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