Soft Tissue Trauma and Burns

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Soft Tissue Trauma and Burns

• Tulsa Technology Center
• Ken Corn, NREMT-P
• Instructor

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Integumentary System

• EPIDERMIS
• Outermost layer of dying skin
• Protective barrier
• Moistened by Sebum to make it waterproof and
  pliable

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Integumentary System

• DERMIS
• Contains blood vessels, glands and nerve endings
• Temperature regulation
• Sweat mechanism
• SubQ adipose cells

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Functions of Skin

• Largest organ
• Keeps the inside in and the outside out
• Sensory organ
• Contains vital body fluids
• Main organ of temperature regulation

• Provides barrier against infection from the
  environment
• Provides insulation from trauma
• Road rash not withstanding!!

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Wounds

• Contusions
• Blunt injuries
• Erythemia, redness caused by contusion
• Ecchymosis, bluish color, late sign
• Hematoma, literally Blood Tumor

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Wounds

• Abrasions-scraping away layers usually little
  bleeding
• Lacerations-jagged open wounds of any depth
• Incisions-clean neat lacerations, lots of blood

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Wounds

• Punctures-small rounded entrance wound that
  normally heals itself, lots of infection
• Avulsions-laceration with a flap hanging off
• Degloving-avulsion stripping all skin off
• Amputation-pretty self explanatory

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Hemorrhage

• Can be arterial, venous, capillary
• Important to determine volume
• Clotting mechanism takes about 10 minutes
• Clean lacs and amputations have little blood
• Crushing injuries involve many tissues and
  hemorrhage control can be very difficult, may
  have to use pressure points etc.

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Thermal Burns

• Causes increased rate of molecular motion causing
  cells to break down
• Tissue injury and death progress rapidly
• Injury is directly related to heat transference
• Energy transferred depends on temperature heat
  source and contact time

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Types of Thermal Burns

• Hot liquids-Boiling water, grease filled liquids
  are worst
• Hot Solids-Stove, iron, fireplace tools
• Hot Gases-from house fires
• Flame
• Superheated steam

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Electrical Burns

• Energy enters and exits body
• This causes an extensive damage track
• Soft tissue, bone and nerves are damaged
• Cardiac arrhythmia's

• Low voltage (lt7000 volts) takes the path of least
  resistance usually blood vessels nerves
• High voltage (gt7000 volts) takes the shortest
  route to ground regardless

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Electrical Burns

• Burns can be FLASH or CONTACT
• Will usually have a small entrance wound (Target
  ring)
• Will usually have a large exit wound (Blowout)

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Chemical Burns

• Destroys cells by biochemical change
• Liquids like drain cleaners
• Dry chemicals like lime or sodium metal
• Acids react with H2O
• Alkalis react with fat

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Radiation Injury

• Ionizing radiation enters a cell and changes its
  make up
• Unshielded radiation from a radioactive source
• Dust debris containing small active particles

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Radiation Types

• Alpha radiation-Weak source blocked by paper,
  skin clothes etc.
• Beta radiation-Greater strength than alpha can
  penetrate skin and clothes
• Gamma radiation-Very powerful penetrates the
  entire body blocked by lead shielding
• Neutron radiation-VERY-VERY dangerous not easily
  blocked by anything

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Radiation Exposure Mechanism

• Radiation exposure has 3 IMPORTANT considerations
• 1-Duration of exposure
• 2-Distance of exposure
• 3-Shielding between you and the radioactive
  source
• Radiation is invisible and cannot be seen or felt
  (If it is your will should be up to date!)

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Inhalation Injury

• Breathing in hot gases, heated air, flame or
  superheated steam
• Inhalation injury is the most common cause of
  burn related death within the first 24 hours

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Toxic Inhalation

• One important consideration is what was on fire,
  the Cleveland Clinic fire of 1929 had 123 deaths
  caused by breathing the oxides of nitrogen
  released by burning x-ray film
• Toxins are given off by resins and plastics as
  they burn. Chemicals such as potassium cyanide
  and hydrogen sulfide
• 40 of the population can smell cyanide and
  whether you can or not is hereditary

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Airway Thermal Burns

• Airway mucosa is damaged from heat
• 1200o F in anethesized dogs
• Superheated steam is needed to burn lower airways
  (Industrial high pressure steam)
• Airway obstruction and respiratory arrest are
  common with thermal burns
• Hoarseness is an important early sign

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Carbon Monoxide (CO) Poisoning

• Suspect in all burn cases especially enclosed
  spaces or if the victim was unconscious
• Hemoglobin as an affinity for CO that is 200
  times greater than the affinity for O2
• CO shoves the Oxygen off of the hemoglobin and
  does not allow oxygen to bind resulting in
  hypoxemia
• Pulse oxemitry is not only of no value for these
  patient but may be DANGEROUS

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Degree of Burn

• FIRST DEGREE
• Involves the upper layer of skin
• Pain minor swelling and redness
• Normally, no complications
• AKA Superficial Burn

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Degree of Burn

• SECOND DEGREE
• Penetrates deeper and produces blisters
• Redness edematous
• Most PAINFUL Burn
• AKA Partial Thickness Burn

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Degree of Burn

• THIRD DEGREE AKA Full Thickness
• Penetrates through the entire epidermis may
  involve muscle or bone
• Destroys nerve endings
• Dry, leathery, gray or white appearance
• Usually painless for lack of nerve endings
• Healing is very difficult and takes FOREVER
  (especially if it is you)

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Adult Rule of Nines

• Head and neck 9
• Front torso 18
• Back torso 18
• Upper extremities 9
• Lower extremities 18 each
• Genitalia 1
• Total 100 cool huh?

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Pediatric Rule of Nines

• Head and Neck 18
• Front torso 18
• Back torso 18
• Upper Extremities 9
• Lower Extremities 13.5 each
• Genitalia 1
• Total 100

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Body Surface Measurement

• Lund and Browder
• Chest abdomen 13
• Buttocks 2.5 each
• Thigh 9.5 each
• Lower leg 7 each
• Foot 3.5 each
• Upper arm 4 each
• Forearm 3 each
• Hand 3 each

• Area equivalent measurement
• Palmar hand surface 1 of BSA

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Special Considerations Complications

• Hypothermia-Excess heat loss from burn
• Hypovolemia-From plasma loss through burn
• Eschar-Formation of dead, necrotic tissue
• Infection, Patients age overall health
• Total Fluid loss
• Associated injuries and illnesses

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BREAK TIME 15 minutes!
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Assessment of Soft Tissue Injury

• Primary assessment
• Control serious bleeding and determine blood loss
• Secondary assessment
• Palpate the injury and determine underlying
  damage
• Note the mechanism of injury
• Prioritize wound injuries and treat appropriately

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Assessment of Thermal Burns

• Note mechanism of injury
• Stop the burning process (DUH!)
• Remove clothing and jewelry
• Assess surface area and severity of burn
• Assess for respiratory involvement
• Assess for associated trauma
• Determine SWAMPLE History

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Assessment of Chemical Burns

• Assess ongoing danger, LOOKOUT!!!!!
• Remove contaminated clothing
• Assess chemical name, exposure time and area
  affected
• Determine if anything was done for the patient
  prior to your arrival
• Determine if there is a specific antidote

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Assessment of Electrical Burns

• TURN OFF THE POWER
• Stop the burning process (DUH again!)
• Remove all smoldering clothing and jewelry
• Search for entrance and exit wounds determine
  voltage
• Monitor for cardiac dysrrhythmias

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Assessment of Radiation Burns

• Approach carefully and find the expert
• Protect everyone from exposure
• Remove contaminated clothing
• Strip, wash and rinse the patient prior to
  assessment

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Determining Criticality of Burns

• Minor - Superficial burns and small partial
  thickness burns
• Moderate - Partial thickness of gt15 BSA small
  full thickness burns
• Severe Partial thickness of gt30 BSA
• Burns to hands, feet, face, genital or with
  circumfrential patterns are critical
• Toxic inhalation burns are always critical

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Management of Wounds

• Direct pressure and elevation
• Pressure point
• Both of the above
• Pneumatic pressure
• Tourniquet as a last resort

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Management of Wounds

• Get the big chunks off or out grass, glass etc
• Clean is nice but not necessary
• If it is gross looking wash it with a little
  saline to get the big dirty chunks off
• Apply neat sterile dressing (blue side out)
• Immobilization helps clotting
• QUIT LOOKING UNDER THE DRESSING!!

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Management of Wounds (PLO)

• Find the part
• Pick up the part
• Gently rinse off the part
• Place the part in a DAMP sterile dressing
• Place in plastic bag
• Place in 2nd bag and then ON ice not IN ice
• Transport with the pt.

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Management of Thermal Burns

• PROTECT YOURSELF! 1
• Put out the fire, ie stop the burning process
• Use whatevers there
• The burn is a lesser priority than the ABCs
• Assess the mechanism of injury

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Management of Thermal Burns

• GET THE HX OF THE PRESENT ILLNESS
• How long ago?
• Enclosed space? with loss of consciousness?
• What was done? (Pleeeezzee tell me you didnt put
  butter on this burn!!)
• SWAMPLE History
• Consider ET SOONER rather than LATER

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Management of Thermal Burns

• For small burns lt15 BSA use moist sterile
  dressings
• For serious burns use DRY DRESSINGS!
• Commercial burn dressing are great but a standard
  hospital sheet works as good
• DO NOT make your patient hypothermic
• DO NOT forget the ABCs

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Management of Electrical Burns

• PROTECT YOURSELF! 1 DO NOT TOUCH A POSSIBLY
  CHARGED PATIENT
• Determine the amount of current (high or low
  voltage or even lightning)
• Determine the duration of exposure
• Deep burn or superficial burn? (Arc flash)
• Treat skin burns like any thermal burn
• Monitor EKG, consider Lidocaine (Electricity is
  NOT good for your heart but falling is!!!)

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Management of Chemical Burns

• PROTECT YOURSELF! 1
• Put out the fire, ie stop the burning process
• Remove patients clothes including underwear and
  jewelry
• Flush with large volumes of water, the wetter the
  better (Urine is a sterile fluid)
• Scrub wounds if appropriate (dry lime)
• If the patients eyes are involved remove
  contacts irrigate copiously with saline (nasal
  cannula)

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Management of Chemical Burns

• Check to see if special fluids need to be used
  (Oil for Na K metal, alcohol for phenol)
• Check for antidote (calcium gluconate for
  hydrofluoric acid)
• Be aware of fire potential for certain chemicals
  (gasoline)
• NO IV UNTIL DECONTAMINATION
• Avoid water with sulfuric acid, use soap

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Management of Radiation Burns

• PROTECT YOURSELF! 1
• Remove and shield patients
• Wash and rinse the patients BEFORE you
  contaminate your unit
• Care for injuries as appropriate
• If the patient was exposed to ionizing radiation
  but not contaminated you are not in danger,
  otherwise they are contaminated

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IV Therapy for Burn Care

• OBJECTIVES
• Maintain pulse rate below 110/min
• Maintain normal mentation
• Maintain urine output between 30-50 ml/hour
• lt 20 ml/hour is bladder sweat

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IV Therapy for Burn Care

• PARKLAND BURN FORMULA
• 4.0 ml lactated Ringers/kg of body weight times
  BSA burned over the first 24 hours
• Give 50 in the first 8 hours post burn
• Give 50 during the next 16 hours
• Second 24 hour give 2000 ml D5W to avoid
  hypernatremia blood or plasma if needed

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IV Therapy for Burn Care

• BROOKE BURN FORMULA
• 2.0 ml lactated Ringers/kg of body weight times
  BSA burned over the first 24 hours
• Give 50 in the first 8 hours post burn
• Give 50 during the next 16 hours
• Second 24 hour give 2000 ml D5W to avoid
  hypernatremia blood or plasma if needed

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Special Considerations for Burn Care

• At the scene, the burn injury is the LEAST
  priority (You remember, A-B-C)
• You may have the best chance to intubate the
  patient, may not be possible later
• Be aware of eschar formation on the chest and
  extremities (You may have to perform an
  escharotomy)

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Special Considerations for Burn Care

• Consider breathing treatments for toxic
  inhalation along with high flow O2
• Development of rales and pulmonary edema are a
  VERY GRAVE sign
• If the patients skin is burned and you can see a
  vein go ahead and use it, its sterile
• No IVs on chemical burn patients unless they have
  been COMPLETELY deconed

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Dont forget rule 1

• PROTECT YOURSELF and watch your partners back!!

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Have a good winter break!!