Ch. 24- Burns
A burn is an injury to the tissues of the body caused by heat, chemicals, electric current, or radiation.
Types of Burn Injury
Thermal Burns (most common)
o Caused by flame, flash, scald, or contact w/ hot objects
o Severity of injury depends on the temp of burning agent and duration of
contact time.
o Scald injuries can occur in bathrooms or while cooking
o Flash, flame, or contact burns occur while cooking, smoking, burning
leaves in backyard, or using gasoline or hot oil.
Chemical Burns
o Result of contact w/ acids, alkalis, and organic compound
o In addition to tissue damage, eyes can be injured if splashed w/
chemicals
o Acids found in home & at work include: hydrochloric, oxalic, and
hydrofluoric acid.
o Alkali burns can be more difficult to manage than acid burns bc alkalis
adheres to tissue causing protein hydrolysis (chemical breakdown of a compound due to reaction w/ water) and liquefaction.
Alkalis are found in cement, oven & drain cleaners, and heavy industrial cleaners
o Organic compounds, including phenols (chemical disinfectants) and petroleum products (creosote & gasoline), produce contact
burns and systemic toxicity.
Smoke & Inhalation Injury
o Breathing noxious chemicals or hot air which can cause damage to the resp tract.
o Smoke inhalation injuries are a major predictor of mortality in burn pts. Rapid initial and ongoing assessment is critical
o Airway compromise & pulmonary edema can develop over the first 12 to 48 hours.
o Types:
Metabolic Asphyxiation
The majority of death at a fire scene are the result of inhaling certain smoke element (carbon monoxide [CO]or
hydrogen cyanide)
, O2 delivery to or consumption by tissues is impaired resulting in hypoxia & death when carboxyhemoglobin
(i.e., hemoglobin combined w/CO) blood levels are > 20%.
CO & hydrogen cyanide poisoning may occur in the absence of burn injury to the skin.
Upper Airway Injury
Results from inhalation injury to the mouth, oropharynx, & or larynx caused by thermal burns or the inhalation
of hot air, steam, or smoke.
Flame burns to the neck and chest may make breathing more difficult bc of the burn eschar, which becomes
tight and constricting from the underlying edema.
Swelling from scald burns to the face and neck can also be lethal, as can exert pressure from edema pressing on
the airway.
Mechanical obstruction can occur quickly, presenting a true airway emergency.
Mucosal burns of the oropharynx & larynx are manifested by redness, blistering, and edema (swelling is massive
& onset rapid)
Flam burns to the neck and chest ma make breathing more difficult bc of the burn eschar, which becomes tight
and constricting from the underlying edema
Swelling from scald burns to the face and neck can also be lethal, as can external pressure from edema pressing
on the airway
Hoarseness, difficulty swallowing, copious secretions, stridor
Substernal and intercostal retraction
Total airway obstruction
Lower airway Injury
Inhalation injury to the trachea, bronchioles, and alveoli is usually caused by breathing in toxic chemicals or
smoke.
Tissue damage rt the duration of exposure to toxic fumes or smoke.
Pulmonary edema may not appear until 12 to 48 hrs after the burn, & then it may manifest as ARDS.
Manifestations:
o High degree suspicion if pt was trapped in a fire in an enclosed space or clothing caught fire
o Presence of facial burns or singed nasal or facial hair
o Dyspnea, carbonaceous sputum, wheezing, hoarseness, altered mental status
o Darkened oral and nasal membranes
Electrical Burns
, o Results from intense heat generated from an electric current.
o Direct damage to nerves and vessel causes tissue anoxia and death.
o Severity of electric injury depends on amount of voltage, tissue resistance, current pathways, surface area in contact w/ the
current, & length of time that current flow was sustained.
o Tissue densities offer various amount of resistance to electric current
Ex: Fat and bone offer the most resistance, whereas nerves and blood vessels offer the least resistance
o Current that passes through vital organs (e.g., brain, heart, kidneys) produces more life-threatening sequelae than that which
passes through other tissues
o Elective sparks may ignite the pt’s clothing, causing a flash injury
o The severity of an electrical injury can be difficult to determine, since most of the damage is below the skin (known as the
iceberg effect)
o Determination of elective current contact points and history of the injury may help reveal the likely path of the current and
potential areas of injury
o Contact w/ electric current can cause muscle contractions strong enough to fracture the long bones and vertebrae
Also long bone or spinal fracture can results from falls due to the electric injury
Consider all pts w/ electrical burns to be at risk for a cervical spine injury
Use cervical spine immobilization during transport and subsequent diagnostic testing until injury is ruled out
o Pts are at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria.
o Electric shock can cause immediate heart standstill or ventricular fibrillation.
o Delayed dysrhythmias or arrest can also occur w/o warning during the first 24hrs after injury
o Myoglobin from injured muscle and Hgb from damaged RBCs are released into the circulation whenever massive muscles and
blood vessel damage occurs
Released myoglobin travels to the kidneys and can block the renal tubules resulting in acute tubular necrosis (ATN) and
acute kidney injury
Cold Thermal Injury (Frostbite)
o True tissue freezing that results in the formation of ice crystals in the tissues and cells.
o Peripheral vasoconstriction is the initial response to cold stress and results in a ↓in blood flow and vascular stasis.
o As cellular temp and ice crystals form in intracellular spaces, the organelles are damaged & the cell membrane destroyed
resulting in edema
o Depth of frostbite depends on ambient temp, length of exposure, type and condition (wet or dry) of clothing, and contact w/
metal surfaces.
, Other factors that affect severity include skin color (dark-skinned people are more prone to frostbite), lack of
alimatization, previous episodes, exhaustion, and poor peripheral vascular status.
o Superficial frostbite
Involves skin and subcutaneous tissue, usually the ears, nose, fingers, and toes.
Skin appearance ranges from waxy pale yellow to blue to mottled & skin feels crunchy and frozen.
Pt may complain of tingling, numbness, or burning sensation.
Handle the area carefully and never squeeze, massage, or scrub the injured tissue bc it is easily damaged.
Remove clothing and jewelry bc they may constrict the extremity and ↓ circulation.
Immerse the affected area in a water bath (98.6° to 104° F) [37° to 40° C]).Use warm soaks for the face.
Pt often experiences a warm, stinging sensation as tissue thaws.
Blisters form w/in a few hrs and should be debrided and a sterile dressing applied.
Avoid heavy blankets & clothing bc friction and weight can lead to sloughing of damaged tissue.
Rewarming is extremely painful. Residual pain may last weeks or even years.
Administer analgesia and tetanus prophylaxis as appropriate. Evaluate pt for systemic hypothermia.
o Deep frostbite
Involves muscle, bone, and tendon
Skin is white, hard, and insensitive to touch & area has the appearance of deep thermal injury w/ mottling gradually
progressing to gangrene.
Affected extremity is immersed in a circulating water bath (98.6° to 104° F) [37° to 40° C]) until flushing occurs distal to
the injured area.
After rewarming, the extremity should be elevated to reduce edema.
Significant edema may begin w/in 3 hours, w/ blistering in 6 hours to days.
IV analgesia is required in severe frostbite bc of the pain associated w/ tissue thawing.
Provide tetanus prophylaxis and evaluate the pt for systemic hypothermia.
Amputation may be required if the injured area is untreated or treatment is unsuccessful.
It may take as long as 90 das for the final demarcation of the necrotic area
Pt may be admitted to the hospital for observation w/ bed rest, elevation of the injured part, and prophylactic antibiotics
if the wound is at risk for infection.
A burn is an injury to the tissues of the body caused by heat, chemicals, electric current, or radiation.
Types of Burn Injury
Thermal Burns (most common)
o Caused by flame, flash, scald, or contact w/ hot objects
o Severity of injury depends on the temp of burning agent and duration of
contact time.
o Scald injuries can occur in bathrooms or while cooking
o Flash, flame, or contact burns occur while cooking, smoking, burning
leaves in backyard, or using gasoline or hot oil.
Chemical Burns
o Result of contact w/ acids, alkalis, and organic compound
o In addition to tissue damage, eyes can be injured if splashed w/
chemicals
o Acids found in home & at work include: hydrochloric, oxalic, and
hydrofluoric acid.
o Alkali burns can be more difficult to manage than acid burns bc alkalis
adheres to tissue causing protein hydrolysis (chemical breakdown of a compound due to reaction w/ water) and liquefaction.
Alkalis are found in cement, oven & drain cleaners, and heavy industrial cleaners
o Organic compounds, including phenols (chemical disinfectants) and petroleum products (creosote & gasoline), produce contact
burns and systemic toxicity.
Smoke & Inhalation Injury
o Breathing noxious chemicals or hot air which can cause damage to the resp tract.
o Smoke inhalation injuries are a major predictor of mortality in burn pts. Rapid initial and ongoing assessment is critical
o Airway compromise & pulmonary edema can develop over the first 12 to 48 hours.
o Types:
Metabolic Asphyxiation
The majority of death at a fire scene are the result of inhaling certain smoke element (carbon monoxide [CO]or
hydrogen cyanide)
, O2 delivery to or consumption by tissues is impaired resulting in hypoxia & death when carboxyhemoglobin
(i.e., hemoglobin combined w/CO) blood levels are > 20%.
CO & hydrogen cyanide poisoning may occur in the absence of burn injury to the skin.
Upper Airway Injury
Results from inhalation injury to the mouth, oropharynx, & or larynx caused by thermal burns or the inhalation
of hot air, steam, or smoke.
Flame burns to the neck and chest may make breathing more difficult bc of the burn eschar, which becomes
tight and constricting from the underlying edema.
Swelling from scald burns to the face and neck can also be lethal, as can exert pressure from edema pressing on
the airway.
Mechanical obstruction can occur quickly, presenting a true airway emergency.
Mucosal burns of the oropharynx & larynx are manifested by redness, blistering, and edema (swelling is massive
& onset rapid)
Flam burns to the neck and chest ma make breathing more difficult bc of the burn eschar, which becomes tight
and constricting from the underlying edema
Swelling from scald burns to the face and neck can also be lethal, as can external pressure from edema pressing
on the airway
Hoarseness, difficulty swallowing, copious secretions, stridor
Substernal and intercostal retraction
Total airway obstruction
Lower airway Injury
Inhalation injury to the trachea, bronchioles, and alveoli is usually caused by breathing in toxic chemicals or
smoke.
Tissue damage rt the duration of exposure to toxic fumes or smoke.
Pulmonary edema may not appear until 12 to 48 hrs after the burn, & then it may manifest as ARDS.
Manifestations:
o High degree suspicion if pt was trapped in a fire in an enclosed space or clothing caught fire
o Presence of facial burns or singed nasal or facial hair
o Dyspnea, carbonaceous sputum, wheezing, hoarseness, altered mental status
o Darkened oral and nasal membranes
Electrical Burns
, o Results from intense heat generated from an electric current.
o Direct damage to nerves and vessel causes tissue anoxia and death.
o Severity of electric injury depends on amount of voltage, tissue resistance, current pathways, surface area in contact w/ the
current, & length of time that current flow was sustained.
o Tissue densities offer various amount of resistance to electric current
Ex: Fat and bone offer the most resistance, whereas nerves and blood vessels offer the least resistance
o Current that passes through vital organs (e.g., brain, heart, kidneys) produces more life-threatening sequelae than that which
passes through other tissues
o Elective sparks may ignite the pt’s clothing, causing a flash injury
o The severity of an electrical injury can be difficult to determine, since most of the damage is below the skin (known as the
iceberg effect)
o Determination of elective current contact points and history of the injury may help reveal the likely path of the current and
potential areas of injury
o Contact w/ electric current can cause muscle contractions strong enough to fracture the long bones and vertebrae
Also long bone or spinal fracture can results from falls due to the electric injury
Consider all pts w/ electrical burns to be at risk for a cervical spine injury
Use cervical spine immobilization during transport and subsequent diagnostic testing until injury is ruled out
o Pts are at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria.
o Electric shock can cause immediate heart standstill or ventricular fibrillation.
o Delayed dysrhythmias or arrest can also occur w/o warning during the first 24hrs after injury
o Myoglobin from injured muscle and Hgb from damaged RBCs are released into the circulation whenever massive muscles and
blood vessel damage occurs
Released myoglobin travels to the kidneys and can block the renal tubules resulting in acute tubular necrosis (ATN) and
acute kidney injury
Cold Thermal Injury (Frostbite)
o True tissue freezing that results in the formation of ice crystals in the tissues and cells.
o Peripheral vasoconstriction is the initial response to cold stress and results in a ↓in blood flow and vascular stasis.
o As cellular temp and ice crystals form in intracellular spaces, the organelles are damaged & the cell membrane destroyed
resulting in edema
o Depth of frostbite depends on ambient temp, length of exposure, type and condition (wet or dry) of clothing, and contact w/
metal surfaces.
, Other factors that affect severity include skin color (dark-skinned people are more prone to frostbite), lack of
alimatization, previous episodes, exhaustion, and poor peripheral vascular status.
o Superficial frostbite
Involves skin and subcutaneous tissue, usually the ears, nose, fingers, and toes.
Skin appearance ranges from waxy pale yellow to blue to mottled & skin feels crunchy and frozen.
Pt may complain of tingling, numbness, or burning sensation.
Handle the area carefully and never squeeze, massage, or scrub the injured tissue bc it is easily damaged.
Remove clothing and jewelry bc they may constrict the extremity and ↓ circulation.
Immerse the affected area in a water bath (98.6° to 104° F) [37° to 40° C]).Use warm soaks for the face.
Pt often experiences a warm, stinging sensation as tissue thaws.
Blisters form w/in a few hrs and should be debrided and a sterile dressing applied.
Avoid heavy blankets & clothing bc friction and weight can lead to sloughing of damaged tissue.
Rewarming is extremely painful. Residual pain may last weeks or even years.
Administer analgesia and tetanus prophylaxis as appropriate. Evaluate pt for systemic hypothermia.
o Deep frostbite
Involves muscle, bone, and tendon
Skin is white, hard, and insensitive to touch & area has the appearance of deep thermal injury w/ mottling gradually
progressing to gangrene.
Affected extremity is immersed in a circulating water bath (98.6° to 104° F) [37° to 40° C]) until flushing occurs distal to
the injured area.
After rewarming, the extremity should be elevated to reduce edema.
Significant edema may begin w/in 3 hours, w/ blistering in 6 hours to days.
IV analgesia is required in severe frostbite bc of the pain associated w/ tissue thawing.
Provide tetanus prophylaxis and evaluate the pt for systemic hypothermia.
Amputation may be required if the injured area is untreated or treatment is unsuccessful.
It may take as long as 90 das for the final demarcation of the necrotic area
Pt may be admitted to the hospital for observation w/ bed rest, elevation of the injured part, and prophylactic antibiotics
if the wound is at risk for infection.
