1 Air Evac Lifeteam Clinical Care Services 5 th Month-Module 1 Proprietary property of Air Evac EMS...

1

Air Evac Lifeteam

Clinical Care Services

5th Month-Module 1

Proprietary property of Air Evac EMS Inc.

Disclosure

• The author/ speaker has no actual or potential conflict of interest in relation to this presentation

• Vendor products mentioned and/or shown as examples

• No unapproved or off-label usages will be discussed

Proprietary property of Air Evac EMS Inc. 2

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Course Objectives• Review of pertinent anatomy and physiology as it relates

to burn injury• Define the magnitude and severity of a burn injury. • Identify and establish priorities of treatment for burn

injuries. • Apply correct methods of physiological monitoring. • Determine the appropriate guidelines for transfer of a

patient, including factors of time, facility and method of transport.

• Provide primary treatment of the burn area, associated injuries and common complications within the first 24 hours post-burn.


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Pathophysiology of Burn Injury

• Initial Burn Injury

– Three phases

• Delayed Injury

– Ongoing Inflammation


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• Heat Induced Injury– Excess heat causes protein breakdown

and cell damage or death– Depth of injury depends on depth of heat

penetration


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Minor Burn Major Burn

Inflammation

Local Mediators:

Histamine, Leukotrienes, Serotonin, Prostaglandins

Circulating Mediators:

Tissue Necrosis Factor, Interleukin, Interferon

Systemic Response

Immune Suppression/ Hypermetabolism

Sepsis/ MODS Proprietary property of Air Evac EMS Inc.

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• Inflammatory Mediator Injury (Day 1-3)– Much of the tissue damage is caused by

toxic mediators of the inflammatory response

– Inflammation is necessary for healing but excess mediator production increases capillary and skill cell damage


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• Inflammatory induced wound injuries include:– Tissue growth factors– Inflammation– Tissue perfusion/ hypoxia– Coagulation cascade


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• Ischemia induced injury

– Tissue necrosis

– Eschar and/or compartment syndrome considerations


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• Delayed Injury– Ongoing inflammation– Wound care and burn center treatment is

aimed at stopping the inflammatory process


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Patho


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• Burn shock

–Distributive shock (early)

–Hypovolemic shock (late)

Q1


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• Burn Injury– Initially

CO and Metabolic rate• With successful resuscitation

– Hypermetabolic– CO doubles


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Clinical Phases of Burn Care

• Phase I (Day 1 – 3)– Initial evaluation/ resuscitation

• Phase II (Day 1 – 7)– Wound excision/ closure

• SIRS Infection Sepsis


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Clinical Phases of Burn Care

• Phase III (Day 7 – Week 6)– Definitive wound closure

• Phase IV (Day 1 – Discharge)– Rehabilitation

• Scar Management Programs• OT/PT• Social Work• Ophthalmology


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Initial Approach

• Standard Primary and Secondary Survey– All burn patients are TRAUMA patients too!

• Burn Specific Secondary Survey– Determine MOI

– Presence of inhalation injury?

– Carbon Monoxide?

– Assessment of wound/ Extent of wounds

– Abuse considerations?

– Ophthalmologic involvement?Q2


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Primary Survey

• Stop the burning process!!– Do NOT COOL the patient– Neutralize heat source– Remove smoldering clothing

• Burns are RARELY immediately life threatening but they are ALWAYS distracting! – Look for OTHER traumatic injuries

• ABC’s and C-spine restriction– Burn patients are TRAUMA patients too!Q3


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Burn Specific Assessment• Mechanism of Injury

– What kind of injury?• Thermal• Electrical• Chemical• Other/ Mixed

– Suspicion of other trauma• Based on evaluation of MOI/ patient presentation

– History of event• Enclosed space• Products of combustion• Loss of consciousness


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Burn Specific Assessment

• Airway Involvement

– Abnormalities of oxygenation and ventilation are common in the immediate post-burn period

– Presence of an inhalation injury is the major cause of mortality in thermal injured patients

Q4


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Airway Involvement

• What factors determine the extent of inhalation injury– Exposure time– Types of toxic fumes exposed to– Concentration of those fumes– Severity of thermal injury– Concomitant trauma/ injuries– Pre-existing medical conditions (Co-

morbidities)Proprietary property of Air Evac

EMS Inc.

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Inhalation Injury


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Inhalation Injuries

• Four different causes of airway, pulmonary and tissue oxygenation abnormalities


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Carbon Monoxide Intoxication

• One of the leading causes of death in fires

• Oxygen used in process of combustion releases carbon monoxide

• Impaired oxygen delivery

• Saturation of the respiratory enzyme


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• Signs and Symptoms

– Depend on the level of toxicity

– Consistent with signs of oxygenation

• CNS

• CV


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• Treatments

– Rapid displacement of CO on the Hgb using Hi Flow Oxygen

– Hyperbaric Oxygen therapy


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Cyanide Toxicity

• Signs and Symptoms– Will be very similar to those of CO

toxicity• Treatments

– Will depend on levels– Supportive care is usually sufficient– Pharmacologic treatment


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Upper Airway Injuries

• Injuries above the glottic opening!• Direct heat injury is caused by inhaling

super heated air

Q5


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Inhalation Injuries

• Does the presence of a body burn affect the severity of the airway injury?


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• Signs and Symptoms

– Don’t just look for soot

– Airway noise

– The typical signs and symptoms we are told to look for do NOT develop until critical airway narrowing has developed!


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• The age old question… Should we intubate or not???– Use your BEST clinical judgment– When in doubt – YES!– Remember, in the absence of 3rd degree burns to

the face and neck, it takes TIME for significant airway and facial edema to occur! (4-18 hours)

Q6


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Lower Airway Injuries

• Injuries below the glottic opening are technically Chemical burns– Carbon particles adhere to the mucosa

cilia impairment prevents removal of foreign matter cell membrane damage occurs inflammatory reaction increased pulmonary blood flow worsens edema formation impacts lung compliance and oxygenation


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• Usually seen in unconscious patients with prolonged smoke exposure

– Conscious patients have two mechanisms that protect their lower airways from inhalation of smoke

– Unconscious patients don’t receive the benefit of these protective mechanisms


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• Signs and Symptoms – Early/ Immediate Post Burn Phase (Up to 4 hours)– Irritation (Coughing)– Edema– Sloughing/ Ulceration– Bronchospasm


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• How long will it take before I see life threatening symptoms associated with lower airway injuries??

– 24 – 48 hours lung compliance, ’d ability to clear

sections = WOB = V/Q Mismatch


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Lower Airway Injuries• Treatments

– Fluid resuscitation• Recent research suggests these patients have

increased fluid requirements BUT those requirements will very from patient to patient and fluid regimens should be individualized

• Stick with the formulas and titrate to UO in pre-hospital and transport settings!


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- Early intubation– Humidified Oxygen– PEEP– Bronchodilators


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Impaired Chest Wall Compliance

• Deep 2nd or 3rd Degree Burns or Circumferential 3rd Degree Burns– Loss of elasticity in chest wall tissue will cause

an in WOB to maintain adequate Vt– Eschar does NOT allow for visible edema

formation. Edema DOES develop but it will be BELOW the eschar and it will compress the chest wall making ventilations difficult if not ineffective


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Deep 2nd Degree burns can cause massive edema• Edema will pool in aureolar and axillary

tissue = increased weight on the thoracic cavity

• Chest Wall edema takes 10 – 12 hours to PEAK!

• Signs and Symptoms– Associated with in WOB and Vt


Cue Questions 1 - 5

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• Treatments– Escharatomy

• Necessary when circumferential burns limit perfusion and alter function

• Lengthwise incision through eschar• Performed at the bedside without anesthesia• No pain• No bleeding

Q7


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Escharatomy vs Fasciotomy

• What’s the difference?– Fasciotomy is performed if tissue perfusion

does not return after escharatomy• Fascia is incised in the OR under anesthesia

• Incision down to the muscle in many cases to determine if tissue/ muscle is viable


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Fluid Resuscitation

• Formula

• Types of Fluid

• Endpoints

• Safety Limits


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Fluid Resuscitation• Goal of fluid resuscitation

– Counter and reverse the effects of burn shock– Maintain end organ perfusion while avoiding the

complications associated with over-resuscitation

• The use of formulas– Over time have been found to be inherently accurate and

should only be used as guidelines to determine initial infusion rates and roughly predict volume requirements for the first 24 hours of the burn injury

– Actual fluid resuscitation should be guided by hourly re-evaluation of desired endpoints

Q8


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Fluid Resuscitation

• Parkland Formula– Most widely used– Kg x TBSA x 4cc = volume/ 24 hours

• Modified Brooke Formula– Kg x TBSA x 2cc = volume/ 24 hours

• Consensus Formula– Combines the two formulas


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Fluid Resuscitation• Crystalloids

– Isotonic crystalloids are preferred for initial fluid resuscitation

• LR

• Colloids– Albumin

• No solid research data exists as to the efficacy of any colloid, let alone Albumin, over crystalloid

• Other– FFP, Hypertonic Saline

• No solid research data exists• Controversial


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Fluid Resuscitation

• Why does everyone use LR?– Lower Na concentration and higher pH

concentration• Closer to physiologic levels

– Has a buffering effect on the metabolic acidosis associated with burns

Q9


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Fluid Resuscitation• Controversies exist

– US Army Institute of Surgical Research recently completed a study using the Modified Brooke formula for resuscitation. They concluded:

• Fluid requirements in the first 24 hours routinely exceeded calculated needs

• Fluid requirements were greater than calculated in large burns and patients requiring mechanical ventilation (inhalation injury)

• Fluid requirements did not correlate with burn size and depth (Largest and most extensive burns did not always require the most fluid)


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Fluid Resuscitation• Endpoints

– End Organ Perfusion

• Urine Output

– Adult - 0.5-1.0 ml/kg/hr

– Pediatric – 1.0 ml/kg/hr

• Heart Rate

– Adult < 130

• Blood Pressure

– Adult SBP – 90 –120 mmHg

• Base Deficit

– < 2.0


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Fluid Resuscitation

• Important caveat– It is better to periodically increase the infusion

rate of the fluid than it is to administer small, frequent boluses to reach the desired urine output endpoint

• Boluses should be reserved for hypotension in the early stages of the burn injury

• Boluses will cause transient elevations in hydrostatic pressure that worsen edema


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Fluid Resuscitation

• Safety Limits– Pulmonary complications associated with

excess fluid• Pulmonary edema

• ARDS

– Increased compartment pressures/worsening of edema requiring the need for escharatomy or fasciotomy


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Wound Care-Pre-hospital• Stop the burning

– Synthetics used in clothing manufacturing will retain heat, be sure to remove clothing

– Clothing that is adhered to the skin should be moistened to neutralize heat

• Remove any jewelry or items that could produce a tourniquet effect


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Wound care pre-hospital

• Maintain blisters intact to protect tissue and maintain normothermia

• Clean, dry sheets to cover

– No creams or ointments

• Pain management


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Pain Control

• Adequate, accurate assessment tools

• Opiates; IV route

• Benzodiazepines work synergistically with opiates


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Prehospital pain management• Inability to assess pain in peds most

common reason for withholding pain meds

• Pain score documented in 67% adults• Pain score documented in 4% peds• Inability to assess pain barrier to

providing analgesia

Hennes, Kim, Pirrallo. Prehospital pain management: A comparison of providers’ perceptions and practices. Prehospital Emergency Care. 2005; 9(1):32-39.


Cue Questions 6 - 9

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Special Concerns• Facial burns—risk of respiratory injury; oral

hygiene; promote healing• Ears—prevent breakdown• Eyes—ophthalmology consult as needed, keep

moist• Hands and feet—adequate circulation; maintain in

position of function• Genitalia—meticulous wound care to prevent

infection; urinary concerns 2° swelling


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Common Complications in Burn Patients• Peripheral Neuropathies

– Caused by:• Direct thermal damage to peripheral nerves• Metabolic disturbances• Constricting eschar/ Compartment syndrome• Poor fitting splints


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Common Complications in Burn Patients • Gastrointestinal

– Curling’s Ulcer

• Acute peptic ulcer resulting from severe burns

– Decreased plasma volume = gastric mucousal sloughing

– Pancreatitis

– Hepatic Dysfunction

– Bowel ischemia/ necrosis


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Common Complications in Burn Patients• Neurological

– Peripheral nerve and spinal cord deficits-especially after high voltage electrical injury

– Seizures– Psychosis

• CV– HTN– DVT

• Pulmonary– Pneumonia– ARDS/ Respiratory failure


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Common Complications in Burn Patients• Hematologic

– Thrombocytopenia– DIC

• Renal– ATN/ ARF


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Common Complications in Burn Patients

• EENT– Otitis media– Sinusitis– Complications of ET Intubation

• Vocal cord erosion/ ulcerations• Tracheal stenosis• Necrosis


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Electrical Injuries• Factors that determine the extent or severity of the

injury– Amount of current

• Low, High, High tension– Type of current

• AC, DC

Q11


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Electrical Injuries

– Path of current• Vertical (upper body to lower body),

horizontal (hand to hand)– Length of contact

• Tetany/ “Locked on”– Events associated with injury

• Fall, burns, contact with water


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Electrical Injuries• Components of Electrical Injuries

– First Component – “Hidden” injury• Injury caused by the electrical current• Generates heat along the path it travels through the body

– Damages nerves, blood vessels and muscle– Second Component

• Injury from arcing– Ionization of air particles-don’t necessarily have to be

touching the source-higher the voltage the greater the ability to arc

– Heat generated by arc can cause clothing to ignite and flame burns


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Electrical Injuries

• Components of Electrical Injuries– Third Component

• Flash burn from power source or from clothing ignition


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Electrical Injuries– Fourth Component

• Trauma due to intense muscle spasms– Tetany or “Locked on”

» Tetany can occur at low voltage» A/C produces stronger, constant muscle contractions

in the flexor group of muscles» Will cause a patients grasp to become uncontrollably

“locked on” to the power source» D/C usually produces a single large muscle

contraction that throws the patient away from the power source

» In high voltage or high tension injuries, regardless of the type of current, you are more likely to see tetany and “locked on” syndromes


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Electrical Injuries

• Fracture d/t intense muscle contractions


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Electrical Injuries• Signs and Symptoms

– CNS Dysfunction is most common• Temporary numbness and tingling• Massive depolarization of brain cells can cause

– Central apnea– Amnesia– LOC– Coma


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Electrical Injuries– Cardiovascular

• Arrhythmias are common

– PVC’s - Asystole

• Sudden death is usually due to Fib

– Fib is 3x more likely to occur if current passes arm to arm

• MI is rare unless patient has preexisting cardiac disease


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Electrical Injuries

• Signs and Symptoms– Pulmonary

• Assess for presence of flame burns that could restrict chest wall movement

• Any associated inhalation injury?

• Associated traumatic injury?

– GU• Muscle damage myoglobin release

rhabdomyolosis ATN ARF


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Electrical Injuries

• Signs and Symptoms– Assess for contact points

• Areas where electrical current entered the body and the point that it reached “ground”

• Typically referred to as entrance and exit sites-those are misnomers. The electricity is actually traveling back and forth between the electrical source and the “ground” site.

– Presence of contact points is diagnostic of “hidden” injury


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Electrical Injuries• Prehospital treatments

– SCENE SAFETY!– Ensure patient is removed from power source by qualified

personnel– Evaluation of mechanism/ history of event– Standard trauma evaluation

• Primary & Secondary

– Standard burn evaluation and care• Stop the burning process• ABC’s• Assess contact points• Assess depth and extent of associated thermal injury

Q12


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Electrical Injuries

• Fluid Resuscitation– These patients WILL have greater fluid

requirements but NOT in the prehospital setting.

• Initiate resuscitation using formula

– Interfacility – transfer orders should outline fluid infusion rates and UO targets.

• NG/OG and Foley are absolute MUSTS for transports


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Electrical Injuries• Treatments

– Transportation to specialized center – Observation and monitoring for low voltage events

• Cardiac monitoring• Standard electrolytes/ CK• Very low incidence of any type of permanent or

severe sequelae


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Electrical Injuries

– Admission and monitoring for high voltage/ high tension events• Cardiac monitoring• Standard electrolytes• Serial CK examinations to diagnose/ treat

Rhabdomyolosis• Specialized burn care required


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Electrical Injuries

• Special Situations– Pediatric patients

• Their thin skin and higher total body water content lower their resistance to electrical current

– Hand to Hand current path• Highest mortality rate of all electrical

injuries


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Electrical Injuries


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Chemical Injuries• Important Assessment Considerations

– History of the incident• Where did it occur?

– Enclosed space, home, work

• When?• How long before decontamination was initiated?

– Duration of exposure to chemical

• Nature of the incident– Spill, explosion, fire,

• Type of chemical– CHEMTREC – 1-800-424-9300– Looking for information on toxic properties of the chemical


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Chemical Injuries• Signs and Symptoms

– Injuries due to chemical exposure typically have a more grayish brown appearance as opposed to the waxy white or charred appearance associated with thermal injuries.

• Injury is usually deeper than it looks

– Further clinical presentation will depend on the type of chemical and severity of exposure

• Observe for signs of systemic poisoning

– Severe persistent pain AFTER appropriate decontamination has taken place is indicative of ONGOING skin damage!


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Chemical Injuries

• Note the grayish discoloration


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Lime


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Chemical Injuries• Signs and Symptoms

– Special Circumstances• Ocular injury

– Extent of symptoms will be determined by chemical– Continuous eye irrigation (1-2L over length of transport)

» Globe damage may limit air transport

• Ingestion of caustic substances– Gastric emptying is contraindicated– Combitube usage is contraindicated– Don’t administer neutralizing agents– Some sources recommend dilution with water but not if any

degree of airway compromise– Endoscopy services WILL be required


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Chemical Injuries• Prehospital Treatments

– SCENE SAFETY!!– Evaluate history of event– Ensure ALL of chemical is removed

• Powder-brush off before initiating irrigation/decontamination• Remove contaminated clothes

– Ensure appropriate decontamination is occuring/ has occurred

Q13


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Chemical Injuries

-Don’t attempt the use of neutralizing agents - use copious amounts of water in a continuous irrigation

– Tepid water if possible

– Avoid water temperature extremes

– Don’t let contaminated water run onto unaffected skin

• Prehospital Treatments– Once decontamination is completed

• Initiate standard trauma and burn care– Pain management

• Burn center designationProprietary property of Air Evac

EMS Inc.

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Chemical Injuries

• Special considerations– Tar

• DO NOT ATTEMPT TO REMOVE TAR IN THE PREHOSPITAL SETTING

– Wet the tar to remove the heat

– Cover affected area with clean, dry sheets

– Continue with standard burn care/ resuscitation

– No risk of systemic absorption


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Pediatric Burns

•


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Pediatrics• Difference between Adults and Pediatrics• Pediatric patients:

– Thinner skin – more significant burn injury– Very young (< 6 months) are more likely to die

• Inability to shiver-catabolism of fat stores to create energy/ warmth requires lots of oxygen consumption

– Prolonged periods of hypothermia can lead to excessive lactate production and metabolic acidosis

• Immature kidneys make child more prone to fluid overload


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Pediatrics

– Infants, Toddlers and Preschoolers are more likely to be burned as a deliberate act.

– Larger Body Surface Area (BSA) relative to body weight

• Necessitates different assessment tools

• Major factor in evaporative water loss– More prone to hypothermia

– Have greater fluid needs


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Superficial Partial Thickness d/t Hot Liquids


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Pediatric Burns

• Prehospital treatment– Standard trauma and burn assessments– Use the same assessment tools and fluid

resuscitation formulas • Kids have increased fluid needs, but not yet…

– Urine output is the best endpoint for fluid resuscitation

• DON’T be afraid to give kids fluid!


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Pediatric Burns

• Hypothermia is a BIG concern in kids– Increased body surface area– Increased water losses– Potential complications of hypothermia include

cardiac deterioration and pulmonary hypertension

• Pain management– Humane and physiologically important– Feel free to use benzodiazepines for anxiety


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Pediatric pre-hospital pain management

• 22% pediatric patients receive pain meds in the field

• 80% pediatric patients receive pain meds once in the ED

• No significant difference in the rate of prehospital analgesia between children and adults

Swor, McEachin, Seguin, Grall. Prehospital pain management in children suffering traumatic injury. Prehospital Emergency Care. 2005; 9(1):40-43


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Pediatric Burns

• Evaluate for abuse– Observe caretaker/ parent reactions

– Evaluate scene

– Assessment clues• Sharply demarcated lines

– No splash marks

– Typically bilateral and symmetrical

• Patterned burns

• Donut burns

– Mandated reportingQ14


Cue Questions 11 - 16

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American Burn Association Burn Center Referral Criteria

• >20% TBSA 2nd degree burns• >10% TBSA 2nd degree burns age <10 or >50• >5% TBSA 3rd degree burns• Electrical, chemical, smoke inhalation• Face, hands, feet, genitalia, perineum, joints• Coexisting trauma, preexisting disease,

circumferential burns of extremity or chestQ15, 16, 17


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