FIGURE 104.2 Skin burns are classified as superficial, partial thickness, or full thickness A: Superficial burns affect only the outer layer of epidermis B: Partialthickness burns affect the lower layers of dermis C: Full-thickness burns destroy the entire layer of dermis (From Lippincott Williams & Wilkins Comprehensive Dental Assisting , 2012: Lippincott Williams & Wilkins/Jones & Bartlett Learning, Burlington, MA www.jblearning.com Reprinted with permission.) Management First Aid Early cooling is accomplished by running cold water over the injured area If performed in the first 60 minutes after injury, it stops ongoing thermal damage and minimizes edema, reducing progression to full-thickness injury Applying ice directly to the wound is often painful, and the extreme cold can worsen the injury Parents should be instructed not to put grease, butter, or any ointment on the burn because these substances not dissipate heat well and may contaminate the area Intact blisters should not be broken prior to medical evaluation Burns should be covered with a clean cloth or bandage Prehospital Prehospital care providers should focus initially on airway, breathing, and circulation, as they would for any other patient Rapid transport to a hospital setting is crucial Oxygen should be administered The patient should be intubated if there are signs of upper airway compromise or impending obstruction If transport time is likely to be prolonged, intravenous fluids should be started FIGURE 104.3 Examples of burns of various depths A: Superficial: Involves only the epidermis B: Superficial partial thickness: Partially injured dermis, with blistering Note the pink-red color and moist appearance C: Deep partial thickness: Injury involves all of the epidermis and most of the dermis Note the paler, drier appearance than superficial injuries D: Full thickness: Involves destruction of the entire epidermis and dermis Note the area of pallor and charred color These areas may also have a leathery appearance (Reprinted with permission from Cohen BJ, Memmler RL, Hull KL Memmlers the Human Body in Health and Disease 13th ed Philadelphia: Wolters Kluwer; 2015.) Emergency Department Management Specific management of major and minor burns is reviewed in the sections below The final section also addresses management of burns with specific etiologies including inflicted, chemical, and electrical burns Preventing Infection Heat causes coagulation necrosis of tissue, producing a protein-rich medium that nourishes bacterial growth Burns become colonized with potentially pathogenic organisms, primarily from the skin and intestinal flora of the patient and not from exogenous sources Cleansing and debridement reduce substrate for bacterial proliferation and topical antimicrobial therapy reduces the number of microorganisms, but burns are never completely sterilized so the risk of secondary infection is always present Burn wounds are not treated immediately with systemic antibiotics unless infection is clearly present, but must be watched closely for development of subsequent infection MAJOR BURNS CLINICAL PEARLS AND PITFALLS The placement of a sterile sheet over burned areas can provide effective analgesia Consider carbon monoxide and cyanide exposure with house fires and not delay treatment in suspected cases Current Evidence Risk of morbidity and mortality is associated with the size of the burn A large, single-center, prospective study of pediatric burn patients found mortality rates ranging from 3% (30% to 39% TBSA) to 55% (90% to 100% TBSA) In this study, burn size of 62% TBSA was the marker of a significantly increased mortality risk Goals of Treatment The initial management of the significantly burned patient includes protection of the airway, maintenance of breathing, and support of circulation, all with the goal of preventing mortality and disability Initial airway assessment needs to include evaluation and management of potential direct inhalational injury and resultant airway edema, as well as inhaled toxins including carbon monoxide and cyanide Patients should receive supplemental oxygen, as well as appropriate antidotal therapy for toxicologic exposure, respiratory support as needed (potentially including escharotomy for circumferential chest burns), and appropriate intravenous fluid resuscitation to support their circulatory status The goal is to optimize wound care and pain management to minimize disability and improve cosmetic and functional outcomes Clinical Considerations In the appropriate clinical circumstances (fire, usually in an enclosed space) it is important to consider carbon monoxide and cyanide poisoning For carbon monoxide, one should administer 100% O2 and send a carboxyhemoglobin level Indications for potential hyperbaric treatment include loss of consciousness at the scene, persistent neurologic symptoms including seizure, evidence of cardiac injury, or significant elevation of carboxyhemoglobin levels (>25% to 40%) The decision to pursue hyperbaric treatment should be made in conjunction with a toxicologist, poison control center, or hyperbaric physician Cyanide poisoning must be treated before the quantitative level is available Indications to consider hydroxycobalamin treatment for cyanide toxicity include history of cardiopulmonary resuscitation (CPR), abnormal vital signs, intubation, evidence of hypoxic injury, and severe metabolic acidosis Clinical Recognition Recognition of the severely injured burn patient is based on a combination of the severity of burn and TBSA involved Burn shock occurs in adults with burns over 30% of BSA but may occur in children with burns over only 20% of BSA Circumferential burns and full-thickness burns are of the highest concern Triage Considerations Please see triage guidelines in Table 104.1 Major burns should be triaged to rapid physician assessment and care Clinical Assessment As part of the primary trauma survey, the clinician must be vigilant in carefully evaluating all patients for evidence of inhalational injury Patients with a history of fire exposure in an enclosed space, soot in the nose or mouth, or facial or airway burns may require intubation for airway protection These patients may also require treatment for carbon monoxide and cyanide exposure In the secondary survey, it is of the greatest ... KL Memmlers the Human Body in Health and Disease 13th ed Philadelphia: Wolters Kluwer; 2015.) Emergency Department Management Specific management of major and minor burns is reviewed in the... mortality is associated with the size of the burn A large, single-center, prospective study of pediatric burn patients found mortality rates ranging from 3% (30% to 39% TBSA) to 55% (90% to 100%