Soft Tissue Trauma and Burns Tulsa Technology Center Ken Corn, NREMT-P Instructor Integumentary System EPIDERMIS Outermost layer of dying skin Protective barrier Moistened by Sebum to make it waterproof and pliable Integumentary System DERMIS Contains blood vessels, glands and nerve endings Temperature regulation Sweat mechanism SubQ adipose cells Functions of Skin Largest organ Provides barrier Keeps the inside in against infection and the outside out from the Sensory organ environment Contains vital body Provides insulation fluids from trauma Main organ of Road rash not temperature withstanding!! regulation Wounds Contusions Blunt injuries Erythemia, redness caused by contusion Ecchymosis, bluish color, late sign Hematoma, literally “Blood Tumor” Wounds Abrasions-scraping away layers usually little bleeding Lacerations-jagged open wounds of any depth Incisions-clean neat lacerations, lots of blood 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 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 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 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 Electrical Burns Energy enters and Low voltage (<7000 exits body volts) takes the path This causes an of least resistance extensive damage usually blood track vessels & nerves Soft tissue, bone and High voltage (>7000 nerves are damaged volts) takes the Cardiac shortest route to arrhythmia's ground regardless 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) Chemical Burns Destroys cells by biochemical change Liquids like drain cleaners Dry chemicals like lime or sodium metal Acids react with H2 O Alkalis react with fat Radiation Injury Ionizing radiation enters a cell and changes it’s make up Unshielded radiation from a radioactive source Dust debris containing small active particles 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 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!) 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 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 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 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 Degree of Burn FIRST DEGREE Involves the upper layer of skin Pain minor swelling and redness Normally, no complications AKA Superficial Burn Degree of Burn SECOND DEGREE Penetrates deeper and produces blisters Redness & edematous Most PAINFUL Burn AKA Partial Thickness Burn 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) 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? 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% Body Surface Measurement Lund and Browder Area equivalent Chest & abdomen measurement 13% Palmar hand Buttocks 2.5% each surface = 1% of Thigh 9.5% each BSA Lower leg 7% each Foot 3.5% each Upper arm 4% each Forearm 3% each Hand 3% each Special Considerations & Complications Hypothermia-Excess heat loss from burn Hypovolemia-From plasma loss through burn Eschar-Formation of dead, necrotic tissue Infection, Patient’s age & overall health Total Fluid loss Associated injuries and illnesses BREAK TIME 15 minutes! 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 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 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 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 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 Determining Criticality of Burns Minor - Superficial burns and small partial thickness burns Moderate - Partial thickness of >15% BSA small full thickness burns Severe Partial thickness of >30% BSA Burns to hands, feet, face, genital or with circumfrential patterns are critical Toxic inhalation burns are always critical Management of Wounds Direct pressure and elevation Pressure point Both of the above Pneumatic pressure Tourniquet as a last resort 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!! 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. Management of Thermal Burns PROTECT YOURSELF! # 1 Put out the fire, ie stop the burning process Use whatever’s there The burn is a lesser priority than the ABCs Assess the 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 didn’t put butter on this burn!!) SWAMPLE History Consider ET SOONER rather than Management of Thermal Burns For small burns <15% 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 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!!!) Management of Chemical Burns PROTECT YOURSELF! # 1 Put out the fire, ie stop the burning process Remove patient’s 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 patient’s eyes are involved remove contacts & irrigate copiously with saline 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 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 IV Therapy for Burn Care OBJECTIVES Maintain pulse rate below 110/min Maintain normal mentation Maintain urine output between 30-50 ml/hour < 20 ml/hour is bladder sweat IV Therapy for Burn Care PARKLAND BURN FORMULA 4.0 ml lactated Ringer’s/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 IV Therapy for Burn Care BROOKE BURN FORMULA 2.0 ml lactated Ringer’s/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 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) 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 patient’s skin is burned and you can see a vein go ahead and use it, it’s sterile No IVs on chemical burn patients unless they have been COMPLETELY deconed Don’t forget rule #1 PROTECT YOURSELF and watch your partner’s back!! Have a good winter break!!
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