Lecture four burns first Aid

Burns
First Aid and Treatment Options
Anas Bahnassi PhD
4

Introduction:
3Anas Bahnassi PhD CDM CDE
Local response to the burn injury
Zone of coagulation: cell death and immediate coagulation of cellular
proteins
Zone of stasis: damage in microcirculation resulting in compromised
circulation, untreated it will lead to necrosis
Zone of hyperaemia: damage causing production of inflammatory
mediators leading to dilatation of blood vessels

Introduction:
4Anas Bahnassi PhD CDM CDE
General response to the burn injury
Skin is the largest organ in the body and isolates chemically,
thermally, biologically and mechanically the inside from the outside
• A burn destroys these functions
• A burn is three dimensional, it opens up a surface and leads to:
• Loss of water, electrolytes, proteins and heat due to vascular permeability,
which results in the formation of edema
• in burns > 20% TBSA, effects on the whole body are:
• hypovolemia (= shock phase = first 48 hours)
• immunosuppression leading to infection
• impairment of barrier function of the gut leading to translocation of
bacteria (it is therefore important to start enteral feeding early)
• systemic inflammatory response post burn affects the lungs resulting in
Adult Respiratory Distress Syndrome (ARDS), even in the absence of
inhalation injury

Initial Assessment of Burns
• Primary Survey:
A. Airways:
• Secure the airway first.
• Get history as much as reasonably
possible before intubation
• Soot or singed nasal hairs?
Anas Bahnassi PhD CDM CDE 5
Escharotomy
B. Breathing:
• High flow Oxygen for all.
• Escharotomy?
• Listen: verify breath sounds
• Assess rate & depth

• Primary Survey:
C. Circulation:
• Monitor Blood Pressure, Pulse, and Skin
color.
• Establish IV access.
• Warm IV fluids.
• Monitor peripheral pulses in circumferential
burns.

• Primary Survey:
D. Disability:
• Associated Injuries?
• CO poisoning?
• Substance abuse?
• Hypoxia?
• Pre-existing medical condition
E. Exposure:
• Remove clothes and jewelry.
• Ensure warm environment.
• Clean dry blankets.
• It is OK to use water to stop the burning process and clean
but not at the expense of reducing body core
temperature.

• Secondary Survey:
– Repeat primary survey.
– Complete History of Present Illness
(HPI).
• What type of burn (flame, chemical, scald)
• Duration of exposure
• What time did burn occur?
• What treatment already provided?
(chemical brushed off, water to cool, etc)
• Did burn occur in house fire/enclosed
space? (think inhalation injury)

– Order labs and x rays
• CBC, BUN, Cr, Lytes
• Carboxyhemoglobin
• Chest X-ray (CXR)
• Blood gas
• Insert Foley
• EKG (especially in electrical injury)
– Special considerations;
• Abuse patterns
– Children, elderly
• Concomitant trauma
– C-spine precautions
– Trauma protocols if trauma is majority of injuries*

– Determine TBSA
• Use Lund Browder chart.
• Can start with patients
palm = 1% of patients
BSA
• A good online program is
sagediagram.com.
– Need patient weight and
height and age for this
program. Can print out a
graphic with parkland
calculations.
Sagediagram Sample

Major Steps in Burn Treatment
• IV fluids for burns > 10% TBSA
• Wound cleaning, dressing, and serial assessment
(Use Hibiclens and sterile water (not saline – it
stings more when mixed with Hibiclens).
• Supportive measures
• Transfer or referral of selected patients to burn
centers
• Surgery and physical therapy for deep partial-
thickness and full-thickness burns

Commence Fluid Resuscitation
Adults
• Fluid resuscitation is recommended for the following injuries:
– Adults (>15%TBSA burn)
– Children (>10%TBSA burn)
• The goal of fluid resuscitation is to anticipate prevent hypovolaemic
shock.
• A variety of fluids have been recommended for use, such as plasma,
human albumin solution (HAS), dextran and Hartmann’s solution.
• Parkland Formula:
The amount of fluid given in the first 24h (mls)= 3 – 4 mls/kg/TBSA%
Rate:
½ in the first 8h
¼ in the second 8 hrs
¼ in the third 8 hrs
4mls/kg/%TBSA is recommended if the patient
has an inhalation injury, presentation is
delayed, has associated trauma or has a high
voltage electrical injury
http://www.merckmanuals.com/professional/clinical_calculators/v4742853.html

Commence Fluid Resuscitation
Children
• Maintenance fluids should also be added over and above the
Modified Parklands formula for children weighing less than 30kgs.
• Use 5% Dextrose in Lactated Ringer's (D5LR): hypertonic (pH: 4-6.5)
– Each 100ml contains 5g of Dextrose Monohydrate, 600mg of Sodium
Chloride, 310mg of Sodium Lactate Anhydrous, 30mg of Potassium
Chloride, and 20mg of Calcium Chloride Dihydrate.
• Parkland Formula for children:
The amount of fluid given in the first 24h (mls)= 3 – 4 mls/kg/TBSA%
Rate:
½ in the first 8h
¼ in the second 8 hrs
¼ in the third 8 hrs
Add maintenance fluid as follows:
ƒ100mls/kg for 10 kg of weight
ƒ50mls/kg next 10 kg of weight
ƒ20mls/kg remaining 10 kg after

Example:
• 23 Kg child with 20% deep burn
– Resuscitation (Ringer’s Lactate)
• 3 ml X 23 Kg X 20% Burn = 1380 mls
– ½ in 1st 8 hrs post burn = 86 cc/hr
– Maintenance (D5LR)
• 1st 10 Kg: 100 cc/kg/24hr = 1,000
cc/24 hr
• 2nd 10 Kg: 50 cc/kg/24hr = 500
cc/24 hr
• Remaining 3 Kg: 20cc/kg/24hr = 60
cc/24 hr
1560 cc/24 hr = 65cc/hr

(A) Rule of nines (for adults) and (B) Lund-
Browder chart (for children) for estimating
extent of burns.

Inhalation Injury
• The three injury processes,
resulting from smoke exposure, are
presented in the order in which
peak symptoms occur.
– Carbon Monoxide Toxicity- peak
symptoms immediate
– Upper Airway Injury with Potential
Obstruction – peak symptoms can
be delayed for an hour or more
– Lower Airway Injury with Impaired
Gas Exchange- peak symptoms can
be delayed for hours

Inhalation Injury
Carbon Monoxide Toxicity
• Diagnosis:
– Pulse oximeter may be completely normal value
as it only measures O2 level.
– A high index of suspicion in any fire victim with
a history of smoke exposure
– A carboxyhemoglobin level
exceeding 10% total (Morbidity
is related to peak level at scene
not the first value obtained)
– Unexplained metabolic acidosis

Inhalation Injury
Carbon Monoxide Toxicity - Symptoms
Carboxyhemoglobin Normal Levels: 0-5%

Inhalation Injury
Carbon Monoxide Toxicity - Treatments
Awake Obtunded (less than full
mental capacity)
High flow by mask
oxygen (100%)
Until carboxyhemoglobin <10%
Intubate
100% oxygen via positive
pressure ventilation
Hyperbaria used if patient not
responding to 100% Oxygen

Inhalation Injury
Upper Airway Injury
• Diagnosis:
– Direct thermal damage tends to occur in the upper airway because
the oropharynx has a substantial capacity to absorb heat.
– Upper airway thermal injury constitutes an important indication
for intubation, because it is mandatory to control the airway
before airway edema develops during resuscitation.
– The diagnosis of upper airway thermal injury is achieved with
direct laryngoscopic visualization of the posterior oropharyngeal
cavity.
– The decision to intubate should be based on visual evidence of
posterior pharyngeal swelling, mucosal sloughing, or
carbonaceous sputum coming from below the level of the vocal
cords.

Inhalation Injury
Upper Airway Injury
• Treatment:
– Hospital admission for observation and provision of
humidified oxygen, pulmonary toilet, bronchodilators as
needed, and endotracheal intubation as indicated.
– Upper airway thermal burns usually manifest within 48
hours of injury and airway swelling usually is maximal 12
to 24 hours after the injury.
– A patient with an upper airway burn may require airway
protection for 72 hours.

Inhalation Injury
Upper Airway Injury
• Treatment:
– In a patient with a small burn (<15% TBSA), a short course
of systemic or inhaled steroids may facilitate earlier
resolution of airway edema, steroids are contraindicated
in patients with large burns due to the risk of infection
and failure to heal.
– The patient can be extubated based on pulmonary
weaning parameters and the presence of an air leak
around the endotracheal tube.
– Once it is safe to extubate, removing the endotracheal
tube should be expedited because of the potential
nosocomial complication of ventilator-associated
pneumonia.. Anas Bahnassi PhD CDM CDE 22

Inhalation Injury
Lower Airway Injury
• Causes:
– Burn injury to the tracheobronchial tree and the lung
parenchyma results from combustion products in smoke
and, under unique conditions, inhaled steam.
– Numerous irritants in smoke or the vaporized chemical
reagents in steam can cause direct mucosal injury, leading
to mucosal slough and bronchial edema,
bronchoconstriction, and bronchial obstruction.
– This leads to exudate formation and microvascular
permeability, and ultimately may progress to pulmonary
edema, pneumonia, or acute respiratory distress
syndrome (ARDS).

Inhalation Injury
Lower Airway Injury
• Diagnosis and treatment:
– Significant inhalation of aerosolized toxins can reduce
myocardial contractility and cause resuscitation failure.
– Diagnosis of lower airway inhalation injury can be
confirmed by bronchoscopy.
– Still there is a need for a scoring system to correlate
degree of pulmonary injury and outcome has yet to be
developed.
– In patients with lower airway inhalation injuries,
successful treatment requires aggressive pulmonary toilet
and frequent chest physiotherapy.

Types of Burns

http://www.youtube.com/watch?v=CNQ_uW66LfU
Types of Burns

First Degree Burn
• A first degree burn is confined exclusively to the
outer surface and is not considered a significant
burn.
• No skin barrier functions are altered.
• The most common form is sunburn which heals
by itself in less than a week without a scar.
Treat with topical
antimicrobial
(Bacitracin) applied
several times a day

Second Degree Burn
• Second degree burns cause damage to the epidermis
and portions of the dermis.
• Since it does not extend through both layers, it is
termed partial thickness.
• There are a number of depths of a second degree or
partial thickness burn which are used to characterize
the burn.
1. Superficial Second Degree
2. Mid-Second degree-Mid partial thickness
burn
3. Deep Second Degree-Deep partial thickness

Second Degree Burn
Superficial Second Degree
• Involves the entire epidermis and no more than the upper
third of the dermis is heat destroyed.
• Rapid healing occurs in 1-2 weeks, because of the large
amount of remaining skin and good blood supply.
• Scar is uncommon.
• Initial pain is the MOST SEVERE of any burn, as the nerve
endings of the skin are exposed to the air.
1. Debridement of affected skin to expose
underlying wound.
2. Debride blisters that are limiting joint
movement.
3. Clean wound and apply antimicrobial
ointment such as bacitracin.
4. Excellent alternative is the use of skin
substitute which seals the wound and
decrease pain.

Second Degree Burn
Mid-Second degree-Mid partial thickness burn
• Destruction to about half the dermis occurs.
• Healing is slower due to the fact that there is less
remaining dermis and less of a blood supply.
• Pain can be severe but is usually less intense than the
superficial due in part by nerves that are destroyed.
1. Treatment is typically Silvadene cream
and occlusive dressing with a closed
dressing technique.
2. A temporary skin substitute is also a
treatment of choice.

Second Degree Burn
Deep Second Degree-Deep partial thickness
• Most of the skin is destroyed except a small amount of remaining dermis.
• The wound looks white or charred indicating dead tissue.
• Blood flow is compromised and a layer of dead dermis or eschar adheres
to the wound surface.
• Pain is much less as the nerves are actually destroyed by the heat.
• Usually, it is difficult to distinguish a deep dermal burn from a full
thickness burn by visualization.
• The presence of sensation to touch usually indicates the burn is a deep
partial injury.
1. Wash with antimicrobial soap and water.
2. Apply silvadene closed dressing.
3. Often grafting is needed to speed
healing.
4. Monitor for infection.
5. Often converts to full thickness injury.

Third Degree Burn
Full thickness buns
• Both layers of skin are completely destroyed
leaving no cells to heal.
• Any significant burn will require skin grafting.
• Small burns will heal with scar.
• Entire destruction of the epidermis and dermis,
leaving no residual epidermal cells to repopulate.
1. Wash with antimicrobial soap and water.
2. Apply Silvadene cream with a closed
dressing.
3. Grafting is treatment of choice. High risk
for infection.

Outpatient Treatment
• Only patients with superficial dermal burns / deep dermal burns
(partial thickness burns) < 10% TBSA should be treated as
outpatients with exception of the very young & old and those with
burns in special areas.
• Scalds are less likely to be deep except in children.
• Estimate the extent of the burn with the palmar surface of
thepatients hand (from the fingertips to the wrist), it is
approximately 1% of the TBSA.
• Look at the color of the burn.
• Note the presence or absence of blisters.
• Apply digital pressure and observe the capillary refill.
• Give oral analgesics.
• Clean and dress the wound.

Clinical Pharmacy VI:
First Aid
abahnassi@gmail.com
http://www.twitter.com/abpharm
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http://www.linkedin.com/in/abahnassi
Anas Bahnassi PhD CDM CDE

Lecture four burns first Aid

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