Redwood Memorial Hospital Field Care Audit for July 2012

1. BURNIN’ FOR YOU
V. Bonales, M.D.
RMH - PCMD
HumCo EMCC - Paramedic Coordinator

2. BURNS
Skin
Types of Burns
Treatment of Burns

3. BURNS
1.4 million people per year suffer a burn
20 - 25% of serious burns - work related
54 - 180K hospitalized, 5% die
Ages 20 - 29 highest incidence of severe burn followed by
children <9 y.o.
Best treatment is prevention (smoke detectors - 80%
reduction in mortality; lowering water heater
temperature, teaching Stop, Drop, & Roll)

4. SKIN

5. SKIN
“IT RUBS THE LOTION ON ITS SKIN, OR ELSE IT GETS THE
HOSE AGAIN...”

6. SKIN
“IT RUBS THE LOTION ON ITS SKIN, OR ELSE IT GETS THE
HOSE AGAIN...”

7. BURNS
Epidermis
No blood vessels
Dermis
Major functions of skin
Subcutaneous Tissue
Insulation and shock
absorption
Connective Tissue

8. BURNS
Epidermis
No blood vessels
Dermis
Major functions of skin
Subcutaneous Tissue
Insulation and shock
absorption
Connective Tissue

9. BURNS
Skin Functions
Barrier
Water Balance
Temperature Regulation
Excretion
Other (i.e.,Vitamin D production)

10. BURNS
Skin as Barrier
Protects against microbes and debris
Skin as Water Regulator
Stores water and lipids
Semi-impermeable barrier

11. BURNS
Skin as Temperature Regulator
Blood vessels dilate or constrict to control heat
loss
Fat as a thermal insulator
Sweat glands produce perspiration to help cool

12. BURNS
Skin as Excretory Organ
Salts and excess water
Skin as Sensory Organ
Heat, cold, pain, pressure, vibration
Skin as Absorption Mechanism
Semi-permeable allows for absorption of certain
chemicals (i.e., drugs, O2, etc.)

13. BURNS
Skin Layers
Thinnest 0.5mm
Eyelids
Thickest 4mm
Palms & soles

14. BURNS
Skin Layers
Thinnest 0.5mm
Eyelids
Thickest 4mm
Palms & soles

15. BURN TYPES

16. BURN TYPES
LISTEN, I’M VERY BADLY BURNED, SO IF YOU COULD JUST...
YOU SHOT ME...!

17. BURN TYPES
LISTEN, I’M VERY BADLY BURNED, SO IF YOU COULD JUST...
YOU SHOT ME...!

18. BURNS
Severity related to rate of heat transfer from source to skin
Temperature of the heat source
Duration of contact
Heat transfer
Conduction (touch hot iron)
Convection (steam, hot oil)
Radiation
Tissue Conductivity (skin poor conductor)

19. BURNS
Thermal
Electrical
Chemical
Light
Radiation

20. BURNS
Thermal
Most common
Fire, heat from fire
Hot liquid, hot
object (iron)
Steam

21. BURNS
Thermal
Scald
Liquid
(immersion, spill),
grease, steam
Contact
Fire (flash, flame)

22. BURNS
Electrical (1000 deaths
per year)
Power source
Voltage
Current

23. BURNS
Power source
Electrical vs. Lightening
Voltage (V = I (current) x R)
High (Power lines 100K)
Low (Household 110 - 240V)
Highest mortality/morbidity at “third rail” 600V

24. BURNS
Current (Iamp = V/R)
Direct Current
Continuous flow of electrons
Alternating Current
Electron flow changes rhythmically

25. BURNS
AC 3x more dangerous than DC
DC high voltage causes single large contraction that
“throws” victim
AC causes tetanus which prolongs exposure

26. BURNS
Effect Current (milliamps)
Tingling perception 1-4
Let-go current – Children 3-4
Let-go current - Women 6-8
Let-go current – Men 7-9
Skeletal muscle tetany 16-20
Respiratory muscle paralysis 20-50
Ventricular fibrillation 50-120
* 15 - 30mAmp common household circuit breaker

27. BURNS
Resistance
Varies on the water content of the tissue
Bone, fat, skin - poor
Blood vessels, muscles, nerves - good
Sweat or water on skin lowers resistance

28. BURNS
Conducted Electrical
Weapons (CEWs)
Tasers
50,000V in 5 second
pulse (DC)
2.1 mAmps of current
Injuries due to
concurrent trauma or
intoxication

29. BURNS
Conducted Electrical
Weapons (CEWs)
Tasers
50,000V in 5 second
pulse (DC)
2.1 mAmps of current
Injuries due to
concurrent trauma or
intoxication

30. BURNS
Lightening
Kills more people (US) than hurricanes, volcanoes,
tornadoes and earthquakes combined
10 - 30% of lightening strikes hit the ground (30
million times a year in US), most are cloud to cloud
Don’t live in Florida, Atlantic coastline or Southeast
coast of Gulf

31. BURNS
“Branches” measure 30 - 50m
Factors: height, isolation, “pointiness”
3 - 5% suffer “direct strike;” majority are energy from
other object struck (ground, tree, etc.)
A few people a year are “indoor victims” via
telephone lines

32. BURNS
Chemical
Acid
Base
Caustics

33. BURNS
Acids
Coagulation necrosis limits penetration
Bases
Liquefaction necrosis allows greater penetration and
injury
Caustics
Other corrosive materials (bleach, peroxide, etc.)

34. BURNS
2008 - Acids 27K, Bases 40K, other Caustics 71K
Long term morbidity is scarring
Severity related to:
pH (acids 1.0 - 7.4 (neutral) - bases 14.0)
Concentration
Length of contact time
Volume
Physical form (pellets vs liquid vs concentrated forms)

35. BURNS
Radiation
Sunlight
Beta particles
(radioactive fallout)
X-rays

36. BURNS
Radiation
Sunlight
Beta particles
(radioactive fallout)
X-rays

37. BURNS
Unit is the Gray (Gy) = absorption of one joule of
energy per kilogram of matter
Gy = Sievert (Sv) and Sv = 100 rems (Roentgen
equivalent man)
X-ray output measured in millirems 1/1000th rem

38. BURNS
CXR = 100 mrem = 0.1 rem = 0.001 Sv = 0.001Gy
CT Head = 200 mrem = 0.2 rem = 0.002 Sv =
0.002Gy
CT A&P = 1000 mrem = 1 rem = 0.01 Sv = 0.01 Gy
Atm = 58 mrem = 0.058 rem = 0.00058 Sv = 0.00058
Gy per year (Cosmic and ground rays)

39. BURNS
Dose at 1000m at
Hiroshima = 4Gy
50% death rate within
3/4 mile of epicenter
Continued lingering
effects in subsequent
generations

40. BURNS
Dose at 1000m at
Hiroshima = 4Gy
50% death rate within
3/4 mile of epicenter
Continued lingering
effects in subsequent
generations

41. BURNS
Acute radiation syndrome
Clinical symptoms
2-5Gy Hematopoietic syndrome - anemia, neutropenia
5-12Gy Gastrointestinal syndrome - nausea, vomiting,
dehydration, weight loss, anorexia, bloody diarrhea
>30Gy Cerebrovascular syndrome - cerebral edema,
ataxia, hypotension, convulsions

42. BURNS
Lethal doses Clinical symptoms
3.5 Gy Lethal without treatment at 60 days
>7 Gy Lethal with treatment at 60 days
>100 Gy Lethal within hours

43. BURNS
1st degree
2nd degree
3rd degree

44. BURNS
1st degree
2nd degree
3rd degree

45. BURNS
1st degree
Only epidermis
Skin red
Painful
Will heal on own

46. BURNS
2nd degree (Partial
thickness)
Epidermis & upper level of
dermis
Deep red
Very painful
Blisters & swelling
Generally will heal on
own

47. BURNS
3rd degree (Full thickness)
Burn down to SQ layer
Black/white skin
Pain +/-
Blisters +/-
Will need skin grafts to
heal

48. FULL THICKNESS BURN
HAND VS. ROAD FLARE

49. FULL THICKNESS BURN
HAND VS. ROAD FLARE

50. ABOUT BURNS

51. ABOUT BURNS
HE’S MISTER HEAT BLISTER, HE’S MISTER 101...

52. ABOUT BURNS
HE’S MISTER HEAT BLISTER, HE’S MISTER 101...

53. BURN
Severity Factors
Agent and Source
Depth
Body Region
Extent of body affected (BSA)
Age
Other medical conditions

54. BURNS
Agent and Source
Chemicals
Left on skin continues to burn
Can be absorbed through the skin
Electric burns
Small lesions on skin can hide deep internal injuries

55. BURNS
Depth
Increased risk of infection
Increased risk of fluid loss and shock
Increased risk of hypothermia due to loss of
temperature regulation

56. BURNS
Body Region
Face - risk of injury to eye or airway compromise
Hands/Feet - risk of scarring can lead to decreased
range of motion
Circumferential burns - risk of edema leading to
vascular compromise
Genitals - increased risk of bacterial contamination

57. BURNS
Body Surface Area
Rule of 9’s
Rule of Palm
1%

58. BURNS
Body Surface Area
Rule of 9’s
Rule of Palm
1%

59. BURNS
Age
Extremities of age will do worse
Healing time lengthened in the elderly

60. BURNS
Co-existing medical conditions
Respiratory illness patients will do worse
Diabetics and heart patients will have a harder time
with the stress and have a more severe reaction

61. BURNS
A. Minor Burns C. Critical Burns
1. Full-thickness burns involving less than 2% of the body 1. All burns complicated by injuries of the respiratory track,
surface, excluding face, hands, feet, genitalia, or respiratory other soft tissue injuries and injuries to bones.
track.
2. Partial or full-thickness burns involving the face, hands,
2. Partial-thickness burns that involve less than 15% of the genitalia or respiratory track.
body surface.
3. Full-thickness burns involving more than 10% of the body
3. Infants & children – any partial-thickness burn of < 10%. surface.
4. Partial-thickness burns involving more than 30% of the
body surface.
B. Moderate Burns
5. Burns complicated by painful, swollen, or deformed
1. Full-thickness burns that involve 2% to 10% of the body extremities
surface, excluding face, hands, feet, genitalia, or respiratory
track. 6. Burns which by classification are moderate but appear in
a person less than 5 y/o or greater than 55 y/o
2. Partial-thickness burns that involve 15% to 30% of the
body surface. 7. Circumferential burns.
3. Superficial burns that involve more than 50% of the body 8. Infants & children – any full or partial-thickness burn of >
surface. 20%.
4. Infants & children – any partial-thickness burn of
10%-20%

62. TREATING BURNS

63. TREATING BURNS
I LOVE THE SMELL OF NAPALM IN THE MORNING...

64. TREATING BURNS
I LOVE THE SMELL OF NAPALM IN THE MORNING...

65. BURNS
1st rule of EMS: safety, safety, safety, scene safety
Patient is more than the burn
Report agent and source of burn

66. BURNS
Don’t
Apply lotions, creams, sprays, or butter
Apply ice
Break blisters
Clear debris

67. BURNS
Keep burn site clean
Treat for shock
Keep patient warm

68. BURNS
Scene safety
Don’t rescue from a fire unless trained to do so
Think of personal and equipment contamination
Make sure electricity is turned off before
approaching patient

69. BURNS
1. Stop the burning process. 7. Wrap burn in dry sterile dressings. If
possible to not use gauze or other
2. Ensure an open airway. Assess material that sheds.
breathing. Look for airway injury: soot
deposits, burnt nasal hairs and facial 8. Burns to hands and/or feet:
burns
i. Remove rings and jewelry that may
3. Complete initial assessment. constrict with swelling.
4. Treat for shock. Provide high-flow ii. Separate digits with sterile gauze
oxygen. pads
5. Evaluate burn - depth, extent, severity. 9. Burns to eyes:
Determine priority.
i. Do not open eyes
6. Remove clothing and jewelry.
ii. Apply moist sterile gauze pads to
both eyes.

70. BURNS
1. Stop the burning. 5. Apply a dry sterile dressing.
a. Dry chemicals - brush off. Then wash 6. Treat for shock.
area with copious amounts of water.
7. Chemical burns to eyes
b. Wet chemicals - wash area with water
or saline for 20 minutes. Use copious a. Immediately flood both eyes with
amount of water in a gentle flow. water. Hold eyes open. Flush from
medial part of eye to lateral with
2. Remove patients clothing to make affected eye lower than unaffected
sure none of the chemical is trapped in eye.
the clothing.
b. Wash for a minimum of 20
3. Do not contaminate skin that has not minutes.
been in contact with the chemical.
c. Cover both eyes with moist
4. Wear protective clothing and eye dressings.
protection.

71. BURNS
Chemical On-scene
Get MSDS from
company
Bring chemical to
E.D. in a safe
container

72. BURNS
Chemical On-scene
Get MSDS from
company
Bring chemical to
E.D. in a safe
container

73. BURNS
Electrical Signs and symptoms f. Elevated BP or hypotension
with symptoms of shock
a. Entrance and exit burns
g. Restlessness or irritability or
b. Disrupted nerve pathways loss of consciousness
displayed as paralysis
h.Visual difficulties
c. Muscle tenderness, with or
without twitching i. Fractured bones and
dislocations
d. Respiratory arrest or distress
j. Seizures (severe cases)
e. Irregular heartbeat or cardiac
arrest

74. BURNS
Make sure electricity source is turned off.
Provide airway care
Provide basic cardiac life support.
Care for shock and administer high flow oxygen
Care for spinal injuries, head injuries and severe fractures.
Look for two external burns.
Cool burn areas and smoldering clothing as with flame
Apply dry sterile dressing.

75. QUESTIONS...?

76. BURNS
Scene safety
Patient is more than the burn
Remember to treat for shock and hypothermia

77. THANK YOU...!
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78. THANK YOU...!
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docmontey
hcemsgroup.blogspot.co
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Facebook