THERMAL INJURY

A T L S 1 0 TH E D I T I O N
 INTRODUCTION

• Burn and cold injuries constitute a major cause of

morbidity and mortality.

• Attention to basic principles of initial trauma

resuscitation and timely application of simple
emergency measures should minimize the morbidity
and mortality of these injuries.
 Immediate life saving measures for burn injuries:
STOP THE BURNING PROCESS

• Remove the patient’s clothing to stop the burning

process; Do not peel of adherent clothing.
• Brush any dry chemical powders from the wound.
• Decontaminate the burn areas by rinsing with warm
saline irrigation or rinsing in a warm shower
• Once the burning process has been stopped, cover
the patient with warm, clean, dry linens to prevent
hypothermia.
Immediate life saving measures for burn injuries:
AIRWAY

• The airway can become obstructed from direct injury

(inhalation injury) and massive edema resulting from the
burn injury.
• Early evaluation to determine the need for endotracheal
intubation is essential.
• The clinical manifestations of inhalation injury may be
subtle and frequently do not appear in the first 24 hours.
• If the provider waits for x-ray evidence of pulmonary
injury or changes in blood gas determinations, airway
edema can preclude intubation, and a surgical airway
may be required.

•
AMERICAN BURN LIFE SUPPORT (ABLS)
Indications for early intubation include:

 Signs of airway obstruction (hoarseness, stridor, accessory

respiratory muscle use, sternal retraction)
 Extent of the burn (total body surface area burn > 40%–
50%)
 Extensive and deep facial burns
 Burns inside the mouth
 Significant edema or risk for edema
 Difficulty swallowing
 Signs of respiratory compromise: inability to clear
secretions, respiratory fatigue, poor oxygenation or
ventilation
 Decreased level of consciousness where airway protective
reflexes are impaired
 Anticipated patient transfer of large burn with airway issue
without qualified personnel to intubate en route
Immediate life saving measures for burn injuries:
AIRWAY (CONT…)

NOTE!
• Transfer to a burn center is indicated for patients
suspected of experiencing inhalation injury
• Circumferential burns of the neck can lead to
swelling of the tissues around the airway; therefore,
early intubation is also indicated for full-thickness
circumferential neck burns.
Immediate life saving measures for burn injuries:
ENSURE ADEQUATE VENTILATION

• Direct thermal injury to the lower airway is very rare

and essentially occurs only after exposure to
superheated steam or ignition of inhaled flammable
gases.
• Breathing concerns arise from three general causes:
hypoxia, carbon monoxide poisoning, and smoke
inhalation injury.
 Immediate life saving measures for burn injuries:
ENSURE ADEQUATE VENTILATION (CONT…)

• As a baseline for evaluating the pulmonary status of a patient

with smoke inhalation injury, clinicians should obtain a chest x-ray
and arterial blood gas determination.
• The treatment of smoke inhalation injury is supportive. A patient
with a high likelihood of smoke inhalation injury associated with a
significant burn (i.e., greater than 20% total body surface area
[TBSA] in an adult, or greater than 10% TBSA in patients less than
10 or greater than 50 years of age) should be intubated.
• If the patient’s hemodynamic condition permits and spinal injury
has been excluded, elevate the patient’s head and chest by 30
degrees to help reduce neck and chest wall edema.
• If a full-thickness burn of the anterior and lateral chest wall leads
to severe restriction of chest wall motion, even in the absence of
a circumferential burn, chest wall escharotomy may be required.
 Immediate life saving measures for burn injuries:
MANAGE CIRCULATION WITH BURN SHOCK
RESUSCITATION

• After establishing airway patency and identifying

and treating immediately life- threatening injuries,
intravenous access must be established.
• Any patients with burns over more than 20% of the
body surface area needs circulatory volume
support.
• If peripheral IVs cannot be obtained, consider
central venous access or intraosseous infusion.
 Patient assessment:
HISTORY

• A brief history of the nature of the injury may

prove extremely valuable in the management of
the burn patient.
• The history, from the patient or relative, should
include a brief survey of pre-existing illnesses: (1)
diabetes, (2) hypertension, (3) cardiac,
pulmonary and/or renal disease, and (4) drug
therapy. Allergies and sensitivities also are
important. The patient's tetanus immunization
status also should be ascertained.
 Patient assessment:
BODY SURFACE AREA

• The "Rule of Nines" is a useful and practical guide to

determine the extent of the burn.
 Patient assessment:
DEPTH OF BURN

• SUPERFICIAL - First-degree burns (eg, sunburn) are characterized by

erythema, pain, and the absence of blisters. They are not life threatening,
and generally do not require intravenous fluid replacement.
• PARTIAL THICKNESS - Second-degree burns are characterized as either
superficial partial thickness or deep partial thickness.
• Superficial partial-thickness burns are moist, painfuly hypersensitive
(even to air current), potentially blistered, homogenously pink, and
blanch to touch.
• Deep partial thickness burns are drier, less painful, potentially blistered,
red or mottled in appearance, and do not blanch to touch
• FULL-THICKNESS BURNS usually appear leathery. The skin may appear
translucent or waxy white. The surface is painless to light touch or pinprick
and generally dry. Once the epidermis is removed, the underlying dermis
may be red initially, but it does not blanch with pressure. This dermis is also
usually dry and does not weep. The deeper the burn, the less pliable and
elastic it becomes; therefore these areas may appear to be less swollen.
 Secondary survey:
DOCUMENTATION

• Report that outlines the patient’s treatment,

including the amount of fluid given and a
pictorial diagram of the burn area and
depth, should be initiated when the patient
is admitted to the ED.
 Secondary survey:
BASELINE DETERMINATIONS FOR PATIENTS WITH
MAJOR BURNS

• Obtain blood samples for a complete blood count,

type and crossmatch/screen, an arterial blood gas
with HbCO (carboxyhemoglobin), serum glucose,
electrolytes, and pregnancy test in all females of
childbearing age.
• Obtain a chest x-ray in patients who are intubated
or suspected of having smoke inhalation injury, and
repeat lms as necessary.
 Secondary survey:
PERIPHERAL CIRCULATION IN CIRCUMFERENTIAL
EXTREMITY BURNS

• The goal of assessing peripheral circulation in a

patient with burns is to rule out compartment
syndrome.
• Once the pulse is gone, it may be too late to save
the muscle. Thus, clinicians must be aware of the
signs and symptoms of compartment syndrome:
 Pain greater than expected and out of proportion to the
stimulus or injury
 Pain on passive stretch of the a ected muscle
 Tense swelling of the a ected compartment
 Paresthesias or altered sensation distal to the a ected
compartment
 Secondary survey:
PERIPHERAL CIRCULATION IN CIRCUMFERENTIAL
EXTREMITY BURNS (CONT…)

• Compartment syndromes may also present with

circumferential chest and abdominal burns, leading
to increased peak inspiratory pressures or
abdominal compartment syndrome.
• Chest and abdominal escharotomies performed
along the anterior axillary lines with a cross-incision
at the clavicular line and the junction of the thorax
and abdomen usually relieve the problem.
 Secondary survey:
GASTRIC TUBE INSERTION

• Insert a gastric tube and attach it to a suction

setup if the patient experiences nausea,
vomiting, or abdominal distention, or when a
patient’s burns involve more than 20% total BSA.
 Secondary survey:
NARCOTICS, ANALGESICS AND SEDATIVES

• Narcotic analgesics and sedatives should be

administered in small, frequent doses by the
intravenous route only. Remember that simply
covering the wound will decrease the pain.
 Secondary survey:
WOUND CARE
• Gently covering the burn with clean linen relieves
the pain and deflects air currents.
• Do not break blisters or apply any antiseptic agent.
Any applied medication must be removed before
appropriate antibacterial topical agents can be
applied.
• Application of cold compresses may cause
hypothermia. Do not apply cold water to a patient
with extensive burns.
 Secondary survey:
ANTIBIOTICS & TETANUS

• ANTIBIOTICS
There is no indication for prophylactic antibiotics in
the early postburn period. Reserve use of antibiotics
for the treatment of infection.

• TETANUS
Determination of the patient’s tetanus immunization
status and initiation of appropriate management
is very important.
 Other burns injuries:
CHEMICAL BURNS

• Chemical injury can result from exposure to acids,

alkalies, and petroleum products.
• Acidic burns cause a coagulation necrosis of the
surrounding tissue, which impedes the penetration
of the acid to some extent.
• Wound care: Immediately flush away the chemical
with large amounts of warmed water, for at least 20
to 30 minutes, using a shower or hose.
 Other burns injuries:
ELECTRICAL BURNS

• Severe electrical injuries usually result in

contracture of the a ected extremity.
• Patients with severe electrical injuries frequently
require fasciotomies and should be transferred to
burn centers early in their course of treatment.
• Immediate treatment of a patient with a
significant electrical burn includes establishing
an airway and ensuring adequate oxygenation
and ventilation, placing an intravenous line in an
uninvolved extremity, ECG monitoring, and
placing an indwelling bladder catheter.
 Patient transfer:
CRITERIA FOR TRANSFER

• The following types of burn injuries typically require transfer to a burn

center:
• Partial-thickness burns on greater than 10% TBSA.
• Burns involving the face, hands, feet, genitalia, perineum, and major
joints
• Third-degree burns in any age group
• Electrical burns, including lightning injury
• Chemical burns
• Inhalation injury
• Burn injury in patients with preexisting medical disorders that could
complicate management, prolong recovery, or a ect mortality (e.g.,
diabetes, renal failure)
• Any patient with burns and concomitant trauma (e.g., fractures) in
which the burn injury poses the greatest risk of morbidity or mortality.
Burned children in hospitals without quali ed personnel or equipment
for the care of children
• Burn injury in patients who will require special social, emotional, or
rehabilitative intervention
 Patient transfer:
TRANSFER PROCEDURES

• Transfer of any patient must be coordinated with

the burn center staff.
• All pertinent information regarding test results, vital
signs, fluids administered, and urinary output should
be documented on the burn/trauma flow sheet
that is sent with the patient, along with any other
information deemed important by the referring and
receiving doctors.
 COLD INJURY

• TYPES OF COLD INJURY

Two types of cold injury are seen in trauma patients:

• Frostbite
• Nonfreezing injury.

• Frostbite
Damage from frostbite can be due to freezing of
tissue, ice crystal formation causing cell membrane
injury, microvascular occlusion, and subsequent
tissue anoxia.
 Types of cold injury:
FROSTBITE DEGREE

• First-degree frostbite: Hyperemia and edema are

present without skin necrosis.
• Second-degree frostbite: Large, clear vesicle
formation accompanies the hyperemia and
edema with partial-thickness skin necrosis.
• Third-degree frostbite: Full-thickness and
subcutaneous tissue necrosis occurs, commonly
with hemorrhagic vesicle formation.
• Fourth-degree frostbite: Full-thickness skin necrosis
occurs, including muscle and bone with later
necrosis.
 Types of cold injury:
NONFREEZING

• Nonfreezing injury is due to microvascular

endothelial damage, stasis, and vascular occlusion.
With ambient temperature above freezing,
prolonged exposure leads to "trench foot" over
several days while "immersion foot" develops more
slowly at higher temperatures.
• Although the entire foot may appear black, deep
tissue destruction may not be present. Chilblain or
pernio, common among mountain climbers, results
from exposure to dry temperatures just above
freezing leading to superficial ulceration of the skin
of the extremities.
 Cold injury:
MANAGEMENT

• Management of Frostbite and Nonfreezing Cold

Injuries
• Treatment should be immediate to decrease duration of
tissue freezing. Constricting, damp clothing should be
replaced by warm blankets and the patient should be
given hot fluids by mouth, if able to drink.
• Place the injured part in circulating water at 40 degrees
centigrade until the pink color and perfusion return (usually
within 20 to 30 minutes). Avoid dry heat.
 Cold injury:
MANAGEMENT (CONT…)

• Local Wound Care of Frostbite

• The goal of wound care for frostbite is to preserve
damaged tissue by preventing infection, avoiding opening
noninfected vesicles, and elevating the injured area, which
is left open to air. Narcotic analgesics are required.
• Tetanus prophylaxis depends on the patient's tetanus
immunization status. Antibiotics are administered if infection
is obviously present. Only rarely is fluid loss massive enough
to require resuscitation with intravenous fluids.
 Cold injury:
SYSTEMIC HYPOTHERMIA

• Trauma patients are susceptible to hypothermia, and

any degree of hypothermia in them can be detrimental.
Hypothermia is any core temperature below 36°C
(96.8°F), and severe hypothermia is any core
temperature below 32°C (89.6°F).
• Hypothermia is common in severely injured individuals,
but further loss of core temperature can be limited by
administering only warmed intravenous fluids and blood,
judiciously exposing the patient, and maintaining a
warm environment. Avoid iatrogenic hypothermia
during exposure and fluid administration, as hypothermia
can worsen coagulopathy and affect organ function.