Burns and Inhalation Injuries

Question 1

Burns Definition

Answer 1

Injury or damage resulting from exposure to fire, heat, caustics, electricity, or certain radiations

Question 2

Inhalation Injuries

Answer 2

Inhalation Injury = Respiratory tract; URT mainly, LRT possible

When smoke inhalation injury is accompanied by a full-thickness or third-degree skin burn, the mortality rate almost doubles.

Question 3

Smoke

Answer 3

Smoke can result from either pyrolysis (smoldering in a low-oxygen environment) or combustion (burning, with visible flame, in an adequate-oxygen environment).

Smoke is composed of a complex mixture of particulates, toxic gases, and vapors.

The composition of smoke varies according to the chemical makeup of the material that is burning and the amount of oxygen being consumed by the fire.

Question 4

What Kind of Substance does wood, cottom and paper produce when they are burned

Answer 4

Aldehydes (acrolein, acetaldehyde, formaldehyde)

Organic Acids (acetic and formic acids)

Question 5

What kind of substance does polyvinycloride produce when they are burned

Answer 5

Carbon Monixide

Hydrogran Chloride

Phosgene

Question 6

What kind of substance does Polyurethanes produce when they are burned

Answer 6

Hydrogen Cyanide

Question 7

What kind of substance does Flurinated Resins produce when they are burned

Answer 7

Hydrogen Fluride

Hydrogen Bromide

Question 8

What kind of substance does Nitrocellulose Film and Fabrics produce when they are burned

Answer 8

Oxides of Nitrogen

Question 9

What kind of substance does Melamine Resins produce when they are burned

Answer 9

Ammonia

Question 10

What kind of substance does Petroleum Products produce when they are burned

Answer 10

Benzene

Question 11

What kind of substance does Organic Material produce when they are burned

Answer 11

Carbon Monoxide

Carbon Dioxide

Question 12

What kind of substance does Sulfur Continaing Compounds produce when they are burned

Answer 12

Sulfur Dioxide

Question 13

What kind of substance does Fertiizer, Textiles, Rubber produce when they are burned

Answer 13

Hydrogen Chloride

Question 14

What kind of substance does Swimming Pool Water produce when they are burned

Answer 14

Chlorine

Question 15

What kind of substance does Welding Fumes produce when they are burned

Answer 15

Ozone

Question 16

What kind of substance does Metal Works and Chemical Manufactuering produce when they are burned

Answer 16

Hydrogen Sulfide

Question 17

The prognosis of fire victims usually is determined by

Answer 17

1. Extent and duration of smoke exposure
2. Chemical composition of the smoke
3. Size and depth of body surface burns
4. Temperature of gases inhaled
5. Age (the prognosis worsens in the very young or old)
6. Pre-existing health status

Question 18

1st Degree Burns

Clinical Apperance

Answer 18

Depth of Burn: First 2-5 layers of epidermis only

Colour/appearance: Red

Skin texture: Normal

Capillary Refill: Yes

Pinprick Sensation: Yes (tenderness & pain)

Healing: In 5 to 10 days with no scarring

Question 19

1st Degree Burns

Answer 19

minimal depth in skin

–Superficial burn; damage limited to the outer layer of epidermis

–Characterized by reddened skin, tenderness, and pain

–Blisters are not present; healing time is about 6 to 10 days

–The result of healing is normal skin

Question 20

2nd Degree Burns

Clinical Picture

Answer 20

Depth of Burn: Involves epidermis and upper third of dermis

Colour/appearance: Red, may be blistered

Skin texture: Edematous

Capillary refill:Yes

Pinprick sensation: Yes (++ pain)

Healing:

In 10 to 20 days with no to minimal scarring

In 25 to 60 days with dense scar formation

Question 21

2nd Degree Burns

Answer 21

Damage extends through the epidermis and into the dermis but is not of sufficient extent to interfere with regeneration of epidermis

If secondary infection results, the damage from a second-degree burn may be equivalent to that of a third-degree burn.

Blisters usually are present. Healing time is between 7 and 21 days

Resultant healing ranges from normal to a hairless and depigmented skin - texture that is normal, pitted, flat, or shiny

Question 22

Third Degree Burns

Answer 22

Will destroy the full thickness of the skin including both dermis and epidermis and can affect the tissue beneath the skin which can become charred and coagulated

Healing can occur after 21 days or may never occur without skin grafting if the burn is large

The resultant damage heals with hypertrophic scars (keloids) and chronic granulation

Question 23

Third Degree Burns

Clinical Picture

Answer 23

Depth of Burn: Entire epidermis,dermisand extends into the subcutaneous fat

Colour/appearance: White / black or brown

Skin texture: Leathery/ charred

Capillary refill: No

Pinprick sensation:No

Healing: No spontaneous healing, will require grafting

Question 24

Determination of Area - Surface Burns

For Infants

Answer 24

Count 18% if the anterior and posterior surfaces of the head and neck are affected

Count 18% for the anterior and posterior surfaces of each upper limb (total is 18% for both upper limbs)

Count 4 times 9 or 36% for the anterior and posterior surfaces of the trunk, including the buttocks (18% per front and back)

Count 6.75% for the anterior and 6.75% for the posterior surfaces of each lower limb as far up as the buttocks (total 36% for both lower limbs)

1 % for groin

Question 25

Determination of Area - Surface Burns For Adults

Answer 25

The Rule of 9’s applies to Adults ## Footnote Count 9 % if the anterior and posterior surfaces of the head and neck are affected Count 9 % for the anterior and posterior surfaces of each upper limb (total is 18% for both upper limbs) Count 4 times 9 or 36% for the anterior and posterior surfaces of the trunk, including the buttocks Count 9% for the anterior and 9% for the posterior surfaces of each lower limb as far up as the buttocks (total 36% for both lower limbs) 1 % for groin

Question 26

Large 3rd Degree Burns Can Lead To

Answer 26

* Large fluid shifts from the vascular compartment due hyperpermeabilityof the microvasculature * From cell mediated toxin release * Results in * Widespread edema (‘burn edema’) * Hypovolemic shock (‘burn shock’) * Hypovolemia from fluid shifting * Coagulopathic changes such as hemolysis and DIC

Question 27

Burned Skin

Answer 27

**Will lose it elasticity** ## Footnote Can impair local tissue perfusion May cause tissue necrosis

Question 28

If Circumferential Around the Thorax

Answer 28

Burns can decrease chest wall compliance“Third spacing”

Question 29

Tissue Hypoxia

Answer 29

–inhalation of toxic gases –inhalational burns, –or from inadequate perfusion

Question 30

Surface Burns and Cardiac Instability

Answer 30

Early- Decreased CO and Increased SVR Later- Decreased SVR

Question 31

Surface Burns and Metabolic Changes

Answer 31

Initial anaerobic metabolism Develops a hypermetabolic state Presents as Catabolic Hypermatabolism

Question 32

Hypermetabolic State

Answer 32

Caused by massive catechoalmine release post butn Can last up to 2 years post burn

Question 33

Hypermetabolic State is Charaterized By

Answer 33

–Increased metabolic rates –Multi-organ dysfunction –Muscle protein degradation, –Blunted growth, –Insulin resistance –Increased risk for infection

Question 34

Catabolic Hypermetabolism

Answer 34

Pt begins to consume blood and muscle proteins

Question 35

Surface Burns and Immune Function

Answer 35

Decreased immune function Possible reduction in WBC formation

Question 36

Surface Burns and CNS

Answer 36

Patients tend to reset thermo-homeostatic point (~38 degCelsius or higher) due to the hypermetabolic state

Question 37

Surface Burns and Other Complications

Answer 37

–Risk of Pulmonary thromboembolism is high in later stages –Infection, sepsis, and gangrene can all occur –Multi-organ system failure & death –ARDS

Question 38

Anatomic Alterations of the Lungs Thermal Injury

Answer 38

Refers to injury caused by the inhalation of hot gases Usually confined to upper airway: Nasal cavity, oral cavity, pharynx (naso/oro/laryngo) The resultant swelling can cause an emergency airway problem!... ANTICIPATE!!

Question 39

Anatomic Alteration of the Lungs Thermal Injury Manifestations

Answer 39

Blistering Mucosal edema Vascular congestion Epithelial sloughing Thick secretions Acute upper airway obstruction

Question 40

Thermal Injuries and the Distal Airways

Answer 40

* Distal airways are usually spared serious injury because of: * Ability of upper airways to cool hot gases * Reflex laryngospasm * Glotticclosure * Direct thermal injuries usually do not occur below the level of the larynx, except in the rare instance of steam inhalation. * Damage to the distal airways is mostly caused by a variety of harmful products found in smoke.

Question 41

Anatomic Alterations of the Lungs Smoe Inhalation Injury Tracheobronchial Tree and Alveoli

Answer 41

–Inflammation of the tracheobronchial tree –Bronchospasm –Excessive bronchial secretions and mucous plugging –Decreased mucociliarytransport –Atelectasis

Question 42

Smoke Inhalation Injury Pathological Changes

Answer 42

The pathologic changes in the distal airways and alveoli are mainly caused by the following * Irritating and toxic gases * Suspended soot particles * Vapors associated with incomplete combustion and smoke Many of the substances found in smoke are extremely caustic to the tracheobronchial tree and poisonous to the body The progression of injuries that develop from smoke inhalation and burns is described as the early stage, intermediate stage, and late stage

Question 43

Inhalation Injury Early Stage | (0 to 24 hours after inhalation)

Answer 43

* Delayed onset of pulmonary symptoms, from none to marked presentation at 24 hours * Even when extensive body surface burns are evident!

Question 44

Inhalation Injury Early Stage (0 to 24 hours after inhalation) The tracheobronchial tree manifests with:

Answer 44

* Inflammation * Bronchospasm * Increased bronchial secretions * Toxins can slow activity of the mucociliarytransport, further exacerbating secretion retention * Can lead to airway obstruction

Question 45

Inhalation Injury Early Stage (0 to 24 hours after inhalation) Other Complications

Answer 45

* Non-cardiogenic Pulmonary Edema * Secondary to the inflammatory response and “leaky” AC membrane * May also be caused by overhydrationresulting from overzealous fluid resuscitation * In severe cases, acute respiratory distress syndrome (ARDS) also may occur early in the course of the pathology.

Question 46

Inhalation Injury Intermediate Stage 2 to 5 days after inhalation

Answer 46

Improvement/resolution ofupper airway thermal injuries Peaking of the pathologic changesassociated with smoke inhalation deep in the lungs

Question 47

Inhalation Injury Intermediate Stage Signs and Symptons

Answer 47

2 to 5 days after inhalation ## Footnote –Mucous production continues to increase, while mucosal ciliarytransport activity continues to decrease –The mucosa of the tracheobronchial tree frequently becomes necrotic and sloughs (usually at 3 to 4 days) –The necrotic debris, excessive mucous production, and mucous retention lead to mucous plugging and atelectasis –In addition, the mucous accumulation often leads to bacterial colonization, bronchitis, and pneumonia

Question 48

Imtermediate Stage Other Complications

Answer 48

* Pneumonia * Organisms commonly cultured include gram-positive Staphylococcus aureusand gram-negatives (Klebsiella, Enterobacter, Escherichia coli, Pseudomonas) * If not already present, ARDS may develop * When chest wall (thorax) burns are present: * Situation may be further aggravated by the patient’s inability to breathe deeply and cough (Pain, analgesics, immobility, poor lung mechanics…)

Question 49

Inhalaton Injury Late Stage

Answer 49

5 or More Days after Inhalation Progression with concerns now focused on: * Infection * resulting from burn wounds on the body surface * These infections often lead to sepsis and multi-organ failure. * Pneumonia (still) * Pulmonary embolism (secondary to a hypercoagulablestate) **Sepsis-induced multi-organ failure is the primary cause of death in seriously burned patients during this stage.**

Question 50

Inhalation Injury Late Stage Long Term Concerns

Answer 50

Long-term effects of smoke inhalation can result in restrictive and obstructive lung disorders. * Restrictive lung disorder * Develops from alveolar fibrosis and chronic atelectasis. * Obstructive lung disorder * Generally is caused by increased and chronic bronchial secretions, bronchial stenosis, bronchial polyps, bronchiectasis, and bronchiolitis. * Cryptogenic organizing pneumonia (also called bronchiolitisobliteransorganizing pneumonia [BOOP])

Question 51

Inhalation Injury Pathophysiological Mechanism

Answer 51

–Atelectasis –Alveolar Consolidation –Increased Alveolar-Capillary Membrane Thickness –Bronchospasm –Excessive Bronchial Secretions

Question 52

Inhalation Injury Physical Examination

Answer 52

* Vital Signs: Increased RR, HR, BP * Assessment of Upper Airway (Thermal Injury) * Obvious pharyngeal edema and swelling * Inspiratory stridor * Hoarseness; altered voiced * Painful swallowing * Other * Cyanosis * Cough and sputum production * Chest Assessment Findings * Usually normal breath sounds (early stage) * Wheezing, crackles, rhonchi

Question 53

Inhalation Injury Clinical Data-ABGs

Answer 53

* Early stage * Acute respiratory alkalosis with hypoxemia * Severe smoke inhalation and burns * Combined respiratory and metabolic (lactic) acidosis * PaO2 may be normal but tissue hypoxia 2°COHb * Late stage: * Acute respiratory acidosis

Question 54

Inhalation Injury Chest Xray

Answer 54

–Usually normal (early stage) –Pulmonary edema/ARDS (intermediate stage) –Patchy or segmental infiltrate (late stage)

Question 55

Inhalation Injury Oxygenation Indices-Late Stage

Answer 55

* DO2 * Decrease * VO2 * Decrease * C(av)O2 * Decrease * O2ER * Decrease * SvO2 * Decrease

Question 56

Inhalation Injury Hemodynamics-Late Stage

Answer 56

Hypovolemic initially; then more of a septic picture/SIRS with vasodilation * CVP * Decrease * PAP * Decrease * PAWP * Decrease * SV * Decrease * CO * Decrease * SVR * Increased * **PVR** * **Increased**

Question 57

Inhalation Injury Hemodynamics-Early/ Intermediate Stage

Answer 57

Hypovolemic initially; then more of a septic picture/SIRS with vasodilation * CVP * Decrease * PAP * Decrease * PAWP * Decrease * SV * Decrease * CO * Decrease * SVR * Increased * PVR * Normal

Question 58

Inhalation Injury Oxygenation Indices-Early/ Intermediate Stage

Answer 58

* DO2 * Decrease * VO2 * Increase * C(av)O2 * increase * O2ER * Increase * SvO2 * Decrease

Question 59

Blood Carboxyhemoglobin (COHb) Levels and Clinical Manifestation 0-10% COHB

Answer 59

Usually no symptons

Question 60

Blood Carboxyhemoglobin (COHb) Levels and Clinical Manifestation 10-20% COHB

Answer 60

Mild Headache Dilation of cutaneous blood vessels

Question 61

Blood Carboxyhemoglobin (COHb) Levels and Clinical Manifestation 20-30% COHB

Answer 61

Throbbing headache Nausea Vomitting Impaired judgment

Question 62

Blood Carboxyhemoglobin (COHb) Levels and Clinical Manifestation 30-50% COHB

Answer 62

Throbbing headache, possible syncope, Increased RR and HR

Question 63

Blood Carboxyhemoglobin (COHb) Levels and Clinical Manifestation 50-60% COHB

Answer 63

Syncope Increased RR and HR Coma Convulsions Cheyne-Stokes Respirations

Question 64

Blood Carboxyhemoglobin (COHb) Levels and Clinical Manifestation 60-70% COHB

Answer 64

Coma Convulsion Cardiovascular and Respiratory Depression Possible Death

Question 65

Blood Carboxyhemoglobin (COHb) Levels and Clinical Manifestation 70-80% COHB

Answer 65

Cariopulmonary failure and death

Question 66

Inhalation Injury Immediate Assessment

Answer 66

–\*Airway and respiratory status –Cardiovascular status –The percentage of body burned –Depth of burns

Question 67

Inhalation Injury Fluid Resuscitation

Answer 67

* IV access is a priority * Fluid resuscitation (based on a formula) * 4 mL/kg of body weight for each percent of body surface area burned over a 24-hour period. * The patient’s hemodynamic status will usually remain stable at this fluid replacement rate, with an average urine output target of 30 to 50 mL/hrand a central venous pressure (CVP) target of 2 to 6 mm Hg. * U/O 30—50 mL/Hr, CVP 2-6 mmHg ## Footnote **Because this process often leads to overhydrationand acute upper airway obstruction and pulmonary edema, the patient’s fluid and electrolyte status must be monitored carefully.**

Question 68

Early Management

Answer 68

–Easily separated clothing should be removed. –Any remaining clothing should be soaked thoroughly before removing. –When present, burn wounds should be covered to prevent shock, fluid loss, heat loss, and pain. –Infection control includes isolation, room pressurization, air filtration, and wound coverings. Wound care is a sterile procedure. Knowledge of the exposure characteristics of the fire-related accident may be helpful in assessing the potential clinical complications

Question 69

General Management

Answer 69

* Airway management—the elective endotracheal intubationshould be performed on the patient who has inhaled hot gases and demonstrates any signs of impending UAO (ie. Stridor) * Consider early intubation - Awake Intubation with fiberopticbronchoscopy * Heated Active Humidity –Treat hypothermia and thick secretions, mucous plugs and eschar * Bronchoscopy— therapeutic bronchoscopy is often used to clear the airway of mucous plugs and eschar. * Hyperbaric oxygen therapy—may be useful in the rapid elimination of CO and the enhancement of skin graft viability. * Treatment for cyanide poisoning—includes amyl nitrite inhalation and intravenous sodium thiosulfate

Question 70

General Management-Pharmacology

Answer 70

* Antibiotic agents—may be used to treat burn wounds and pulmonary infections * Expectorants—may be administered to facilitate expectoration * Analgesic agents—are generally ordered when surface burns are present * Prophylactic anticoagulants—heparin and other anticoagulants often are administered to patients with severe, long-term fire-related injuries

Question 71

General Respiratory Care

Answer 71

–Oxygen Therapy –Mechanical Ventilation –Bronchopulmonary Hygiene –Lung Expansion Therapy –Aerosolized Medication