Management of Burn Injuries, Smoke Inhalation and Carbon Monoxide Intoxication

| In Articles | 3rd August 2020

IMPORTANCE OF SKIN

The skin is the largest body organ. It is essential for thermoregulation, prevention of fluid loss by evaporation, barrier against infection and protection against the environment. It contains 3 layers: epidermis, dermis and hypodermis.

Epidermis is the outermost layer, composed of cornified epitelial cells. The outer surface cells are dead and sloughed off.

Dermis is the middle layer, composed primarily of connective tissue. It contains capillaries that nourish the skin, nerve endings and hair follicles.

Hypodermis is a layer of adipose and connective tissue between the skin and underlying tissues.

BURN INJURIES

  • Thermal: through direct contact with heat ( flame, scald)
  • Electrical: alternating current A.C. -residential and direct current D.C. -industrial/lightening
  • Chemical
  • Frostbite

CLASSIFICATION OF BURNS

  • Burns are classified by depth, type and extent of injury
  • Every aspect of burn treatment depends on the assessment of depth and extent

DEGREE OF BURNS

A. First degree burns

  • Involves only the epidermis
  • The tissue blanches if pressure is applied
  • Erythematous and painful
  • Minimal tissue damage
  • Include sunburn
  • Signs and symptoms: skin heat, pain, oedema, skin peeling
  • Recovery: 1-2 weeks

B. Second degree burns

  • Partial thickness burns
  • Involve the epidermis and portions of dermis and other structures such as sweat glands and hair follicles
  • Signs and symptoms: blisters, pain, oedema, decreased tissue blood flow
  • Can convert to a full thickness burn
  • Recovery: 3-4 weeks
  • Possible scarring
  • Risk of secondary infections

To remember: burns that blister are second degree but not all second degree burns blister!

C. Third degree burns

  • Full thickness burns
  • Charred skin or white colour
  • Coagulated vessels visible
  • The third degree burn area is lacking physical sensation
  • Pain from surrounding second degree burn area
  • Complete destruction of tissue and structures
  • Complications: secondary infections and disfiguring
  • Most third degree burns require skin grafts

D. Fourth degree burns

  • Involve subcutaneous tissue, tendons and bones
  • Fourth degree burns are life threatening with poor prognosis, particularly if they involve more than a small portion of the body

CRITERIA FOR TRANSFER TO A BURN CENTRE

  • Full-thickness burns more than 5% of the body surface area
  • Partial-thickness burns more than 10% of the body surface area
  • Any full thickness or partial thickness burns involving critical areas - face, hands, feet, genitals, perineum, skin over major joints
  • Children with severe burns
  • Circumferential burns of thorax or extremities
  • Significant chemical injuries, electrical burns, lightening injuries, co-existing major trauma or significant pre-existing medical conditions
  • Inhalation injuries

INITIAL TREATMENT FOR BURNS

  • Stop the burning process
  • Consider the patient as a multiple trauma one until proven otherwise
  • Perform ABCDE assessment
  • Avoid hypothermia
  • Remove constricting clothing and jewellery

FINDING OUT DETAILS ABOUT THE BURN INJURY

  • Cause of burn
  • Time of injury
  • Place of occurrence (closed space, presence of chemicals, noxious fumes)
  • Loss of consciousness?
  • Likelihood of associated trauma (motor vehicle accident/explosion)
  • Pre-hospital interventions

AIRWAY MANAGEMENT FOR BURN INJURY PATIENTS

  • Maintain low threshold for intubation and high index of suspicion for airway injury
  • Swelling is rapid and progressive in the first 24 hours
  • Consider rapid sequence intubation RSI - cautious use of succinylcholine due to potassium increase!
  • Prior to intubation attempt - have smaller sizes of endotracheal tube
  • Prepare for cricothyrotomy or tracheostomy
  • Utilise end-tidal carbon dioxide ETCO2 monitoring as pulse oximetry may be inaccurate in burn injury patients

AIRWAY CONSIDERATION FOR BURN INJURIES

  • Upper airway injury (above the glottis) - area buffers the heat of smoke - thermal injuries are usually confined to the larynx and upper trachea
  • Lower airway/alveolar injury (below the glottis) - caused by the inhalation of steam or chemical smoke and often presents as acute respiratory distress syndrome ARDS after 24-72 hours

CRITERIA FOR INTUBATING PATIENTS WITH BURN INJURIES

  • Changes in voice
  • Wheezing/laboured respirations
  • Excessive, continuous cough
  • Altered mental status
  • Carbonaceous sputum
  • Singed facial or nasal hair
  • Facial burns, eyes swollen shut
  • Oropharyngeal oedema/stridor
  • Assume inhalation injury in any patient confined in a fire environment
  • Extensive face/neck burns
  • Burns 50% or greater of the total body surface area

CIRCUMFERENTIAL BURNS OF CHEST AND ABDOMEN

  • Eschar = burned, inflexible, necrotic tissue
  • Compromises ventilatory motion
  • Surgery - escharotomy - may be necessary

CARBON MONOXIDE INTOXICATION

Carbon monoxide is a colourless, odourless, tasteless product of incomplete combustion. It has a binding affinity for haemoglobin 210-240 times greater than oxygen. Carbon monoxide intoxication results in decreased oxygen delivery to tissues, leading to cerebral and myocardial hypoxia. Cardiac arrhythmias are the most common fatal occurrence.

SIGNS AND SYMPTOMS OF CARBON MONOXIDE INTOXICATION

  • Usually symptoms do not appear until 15% of the haemoglobin is bound to carbon monoxide rather than to oxygen
  • Early symptoms are neurological in nature due to cerebral oxygenation impairment
  • Confused, irritable, restless
  • Headache, vomiting, incontinence
  • Dilated pupils
  • Tachycardia, arrhythmias or infarction
  • Pale or cyanotic complexion
  • Seizures
  • Overall cherry red colour - rarely seen
  • Death - when more than 50-60% of the haemoglobin is bound to carbon monoxide

MANAGEMENT OF CARBON MONOXIDE INTOXICATION

  • Remove the patient from the source of exposure
  • Administer 100% high flow oxygen

The half life of carboxyhemoglobin if the patient is breathing room air is 120-200 minutes and with 100% high flow oxygen it is 30 minutes.

BURN HEMODYNAMICS

The formation of oedema is the greatest initial volume loss. In burns 30% or less of total body surface, oedema is limited to the burnt region. For burns more than 30% of total body surface oedema develops in all body tissues, including non-burned areas.

Burn injury oedema develops due to:

  • Increase in capillary permeability which allows protein molecules to cross the cell membrane
  • Reduced intravascular volume volume
  • Loss of sodium into burn tissue
  • Increased osmotic pressure which continues to draw fluid from the vascular system leading to oedema formation
  • Loss of plasma volume is greatest during the first 4-6 hours, decreasing substantially in 8-24 hours if adequate perfusion is maintained
  • Impaired peripheral perfusion
  • Mechanical compression, vasospasm or destruction of vessels
  • Escharotomy is indicated when muscle compartment pressure is higher than 30mmHg
  • Compartment pressures are best obtained via ultrasound to avoid potential risk of microbial seeding by using slit or wick catheter

FLUID RESUSCITATION FOR BURN INJURY PATIENTS

The goal of fluid resuscitation is to maintain perfusion to vital organs. It needs to be based on the total body surface area, body weight and wether the patient is an adult or child. Fluid overload should be avoided as it is difficult to retrieve settled fluid in tissues and may facilitate organ hypoperfusion.

Fluid volumes may increase in burn injury patients with co-existing trauma. Fluid requirement calculations for infusion rates are based on the time from injury NOT from the time fluid resuscitation is initiated.

HYPOTHERMIA DUE TO BURN INJURIES

  • Hypothermia may lead to acidosis/coagulopathy
  • Hypothermia causes peripheral vasoconstriction and impairs oxygen delivery to the tissues
  • Metabolism changes aerobic to anaerobic

HOW TO TREAT HYPOTHERMIA IN PATIENTS WITH BURN INJURIES

  • Cover patients with dry sheet, head covered
  • Pre warm trauma room
  • Administer warmed IV solutions
  • Avoid application of saline-soaked dressings
  • Avoid prolonged irrigation
  • Remove wet/bloody clothing and sheets
  • Avoid application of antimicrobial creams
  • Remember that paralytics are unable to shiver and generate heat!
  • Monitor the core body temperature

ANALGESIA FOR BURN INJURIES

  • Opioids such as Morphine sulphate: adults 0.1-0.2 mg/kg IVP and children 0.1-0.2 mg/kg/dose IVP/IO
  • Other pain medication: non steroidal anti-inflammatory drugs

GASTROINTESTINAL COMPLICATIONS DUE TO BURN INJURIES

Burns more than 25% of the total body surface area are subject to gastrointestinal complications secondary to hypovolemia and endocrine responses to injury. The insertion of a nasogastric tube may be required to reduce the risk of aspiration and paralytic ileus. Early administration of a H2 histamine receptor antagonist is also important to reduce stomach acid.

HOW TO TREAT BURN WOUNDS

  • Check tetanus status - administer tetanus vaccine as appropriate
  • Debridement of open blisters or those located in areas where they are likely to rupture
  • Debridement of intact blisters is controversial
  • Bacitracin ointment
  • Silvadine cream
  • 5% Sulfamylon solution
  • Silverlon dressing + sterile water (apply dressing and do not remove for 72 hours)
  • Surgery: early excision and grafting, tangential excision, fascial excision
  • After 3 weeks: skin grafting, split thickness skin grafting, full thickness skin grafting

BURN INJURY TREATMENT: SKIN GRAFTING

  1. Obtaining skin
  2. Growing cells in culture
  3. Harvesting skin in culture
  4. Surgical grafting

BURN DEPTH

Burn depth cannot be accurately determined in the acute stage. Infection may convert the burn into a higher degree. When in doubt, it is better to overestimate!

CRITICAL BURNS

  • Full-thickness burns involving hands, feet, face, upper airway, genitalia or circumferential burns of other areas
  • Full-thickness burns covering more than 10% of total body surface area
  • Partial thickness burns covering more than 30% of total body surface area
  • Burns associated with respiratory injuries
  • Burns complicated by fractures
  • Burns on patients younger that 5 years old and older than 55 years old that would be classified as moderate on young adults

MODERATE BURNS

  • Full-thickness burns involving 2 to 10% of total body surface area excluding hands, feet, face, upper airway or genitalia
  • Partial thickness burns covering 15 to 30% of total body surface area
  • Superficial burns covering more than 50% of total body surface area

MINOR BURNS

  • Full thickness burns involving less than 2% of total body surface area
  • Partial thickness burns covering less than 15% of the total body surface area
  • Superficial burns covering less than 50% of the total body surface area

INITIAL ASSESSMENT OF BURN INJURIES

  • Scene safety
  • Determine mechanism of injury/severity
  • Number of patients
  • Additional resources

STOP THE BURNING PROCESS!

  • Remove the patient from the source of injury
  • Remove clothing unless stuck to burn
  • Cut around clothing stuck to burn, leave in place

AIRWAY/BREATHING ASSESSMENT IN BURN INJURIES

  1. Start oxygen if:
  • Moderate or critical burn
  • Decreased level of consciousness
  • Signs of respiratory involvement
  • Burn occurred in closed space
  • History of smoke or carbon monoxide exposure

2. Assisted ventilation if needed

CIRCULATION ASSESSMENT IN BURN INJURIES

Check for signs and symptoms of shock. Early shock seldom results from the effects on burn itself. Early shock means another injury until proven otherwise.

OBTAIN HISTORY

  • How long ago did the burn injury occur?
  • What has been done for the burn injury?
  • What caused the burn?
  • Did the burn injury. happen in a closed space?
  • Has the patient lost consciousness?
  • Do they have any allergies and what medications are they taking?
  • What is their past medical history?

RAPID PHYSICAL EXAM FOR BURN INJURY PATIENTS

  • Check for other injuries
  • Rapidly estimate burned/unburned areas
  • Remember that it is better to overestimate rather than underestimate!
  • Remove constricting bands

SUPERFICIAL BURNS:

  • Cool, moist dressings
  • Protect from exposure to air

PARTIAL/FULL THICKNESS DEGREE BURNS

  • Cover with dry dressings

PAEDIATRIC CONSIDERATIONS

  • Thin skin - increased burn severity
  • Large surface to volume ratio
  • Poor immune response
  • Small airways, limited respiratory reserve capacity
  • Consider the possibility of abuse!

BURNS IN INFANTS AND CHILDREN

Critical burns:

  • Full thickness burns covering more than 20% of the body surface area
  • Burns involving hands, feet, face, upper airway, genitalia

Moderate burns:

  • Partial thickness burns involving 10-20% of the body surface area

Minor burns:

  • Partial-thickness burns less than 10% of body surface area

ELDERLY PATIENTS CONSIDERATIONS

  • Thin skin, poorly circulation
  • Underlying disease processes: pulmonary, peripheral vascular
  • Decreased cardiac reserve
  • Decreased immune response
  • % Mortality = the body surface area burned (age + %)

UPPER AIRWAY BURNS

  • True thermal burn
  • Danger signs: neck/face burns, singing of nasal hairs, eyebrows, tachypnea, hoarseness, drooling, red and dry oral/nasal mucosa

LOWER AIRWAY BURNS

  • Chemical injury
  • Danger signs: loss of consciousness, burned in a closed space, tachypnea, cough, rales, wheezes, rhonchi, carbonaceous sputum

CHEMICAL BURNS

  • Damage to skin
  • Absorption of chemicals: systemic toxic effects
  • Eyes are more vulnerable
  • Fumes can cause burns
  • Emergency medical services personnel exposure
  • To prevent exposure, wear appropriate gloves and eye protection
  • Hazmat incident?

HAZMAT is a type of safety incident that involves the uncontrolled release of one or more hazardous materials into the environment in which humans are or could be present or that otherwise holds the potential to put human or environmental safety at risk if not addressed.

CARE FOR CHEMICAL BURNS

  • Remove the chemical from the patient
  • If it is a powder chemical brush it off first
  • Remove all contaminated clothing
  • Flush the burned area with large amounts of water for 15-20 minutes
  • Transport the patient to the hospital quickly

PHENOL BURNS

  • Not water soluble
  • Flush with alcohol

SODIUM/POTASSIUM/MAGNESIUM BURNS

  • Explode on water contact
  • Cover with oil

TAR BURNS

  • Use cold packs to solidify tar
  • Do not try to remove
  • Tar can be dissolved with organic solvents later

CHEMICAL BURNS TO THE EYE

  • Hold the eyelid open while flooding eye with cold water
  • Continue flushing en route to hospital
  • Do not use other chemicals

ELECTRICAL BURNS

  • Intensity of current
  • Duration of contact
  • Type of current (AC or DC)
  • Width of current path
  • Types of tissues exposed (resistance)
  • Non-conductive injuries: arc burns, ignition of clothing
  • Conductive injuries: "tip of iceberg", entrance/exit wounds may be small, massive tissue damage between entrance/exit

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COMPLICATIONS OF ELECTRICAL BURNS

  • Cardiac arrest/arrhythmias
  • Respiratory arrest
  • Spinal fractures
  • Long bone fractures
  • Internal organ damage

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HOW TO MANAGE ELECTRICAL BURNS

  • Make sure power is off before touching the patient
  • Check airway, breathing, circulation
  • Two wounds to bandage: entrance/exit
  • Transport patient and be prepared to administer CPR
  • Consider airway involvement signs: singed facial hair, soot in the mouth/nose, hoarseness
  • Burns with other injuries: shock, fractures, respiratory problems
  • Partial or full thickness burns to the face
  • Partial or full thickness burns more than 20% of body surface area
  • Severe pain management