Region 5- Just-in-Time Burn Training Expanded Module- Part II

Contents: I. Thermal Burn II. Chemical Burn III. Electrical Burn IV. Radiation Burn/Exposure V. Psychosocial Issues I. THERMAL BURN INJURY A. Introduction 1. Studies have shown that surface temperatures of 44 C (111 F) do not produce burns unless exposure time exceeds 6 hours a. At temperatures between 44 and 51 C (111 and 124 F) the rate of epidermal necrosis approximately doubles with each degree of temperature increase b. At 70 C (185 F) or greater, the exposure time required to cause transepidermal necrosis is less than 1 second 2. The degree of tissue destruction depends on the temperature and duration of exposure to flame, flash, scald or hot objects 3. Factors that influence the bodys ability to resist burn injury include: a. The water content of the skin tissue b. Thickness and pigmentation of the skin c. Presence or absence of insulating substances (e.g., skin oils, hair) d. Peripheral circulation of the skin, which affects dissipation of heat B. Local response to burn injury 1. Burn injury immediately destroys cells, or it disrupts their metabolic functions so completely that cellular death ensues 2. Cellular damage is distributed over a spectrum of injury a. Some cells are destroyed instantly b. Others are irreversibly injured c. Some cells may survive if rapid and appropriate intervention is provided in the prehospital setting 3. Major burns have three distinct zones of injury (Jacksons thermal wound theory) that usually appear in a bulls-eye pattern a. Zone of coagulation 1) The central area of the burn that has sustained the most intense contact with the thermal source 2) Coagulation necrosis of the cells has occurred 3) The tissue is nonviable b. Zone of stasis 1) Surrounds the critically injured area 2) Consists of potentially viable tissue despite serious thermal injury 3) Cells are ischemic because of clotting and vasoconstriction and die within 24 to 48 hours after injury if no supportive measures are undertaken c. Zone of hyperemia 1) Has increased blood flow because of the normal inflammatory response 2) Tissues recover in 7 to 10 days if infection or profound shock does not develop

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4. Tissue damage from burns depends on: a. Degree of heat b. Duration of exposure to the thermal source 5. As a rule, the burn wound swells rapidly because of the release of chemical mediators a. Causes an increase in capillary permeability and a fluid shift from the intravascular space into the injured tissues 6. Injury to the sodium pump in the cell walls accentuates the increased permeability a. As sodium moves into injured cells it causes an increase in osmotic pressure that increases the inflow of vascular fluid into the wound 7. Finally, the normal process of evaporative loss of water into the environment is dramatically accelerated (5 to 15 times that of normal skin) through the burned tissue 8. In a small wound these physiological alterations produce a classic inflammatory response without any major systemic effects a. Pain b. Redness c. Swelling 9. In a large body surface area burn, local tissue responses can produce major systemic effects and life-threatening hypovolemia C. Systemic response to burn injury 1. As local events occur at the injury site other organ systems become involved in a general response to the stress caused by the burn, which may compromise patient outcome 2. An early manifestation of the systemic effects of a large thermal injury is hypovolemic shock associated with the following: a. Decreased venous return b. Decreased cardiac output c. Increased vascular resistance (except in the zone of hyperemia) 3. Other physiological responses can lead to renal failure a. Hemolysis (destruction of red blood cells [RBCs]) b. Rhabdomyolysis (muscle necrosis) 1) Subsequent hemoglobinuria and myoglobinuria (myoglobin in the urine) 2) Other systemic responses to major burn injury a) Pulmonary response (1) Hyperventilation to meet increased metabolic needs b) Gastrointestinal response (1) Decrease in splanchnic perfusion that may lead to mucosal hemorrhage and transient adynamic ileus (2) Vomiting and aspiration (3) Stress ulcers c) Musculoskeletal response (1) Decreased range of motion from immobility and edema (2) Possible osteoporosis and demineralization (late) d) Neuroendocrine response (1) Increased amounts of circulating epinephrine and norepinephrine, and transient elevation of aldosterone levels e) Metabolic response (1) Elevated metabolic rate, particularly with infection or surgical stress f) Immune response
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(1) Altered immunity resulting in increased susceptibility to infection (2) Depressed inflammatory response g) Emotional response (1) Physical pain (2) Isolation from loved ones and familiar surroundings (3) Fear of disfigurement, deformities, and disability (4) Altered self-image (5) Depression D. Classifications of burn injury 1. Ideally, burns should be assessed and classified as accurately as possible in the prehospital and ED setting a. Difficult to do because of the progressive nature of the injury b. Amount of tissue damage from burns may not be evident for hours or sometimes days after the injury 2. Depth of burn injury a. Classified as first, second, and third degree b. First- and second-degree burns are partial-thickness burns (if uncomplicated by infection or shock) 1) Usually heal without surgery c. Third-degree burns are full-thickness burns that usually require skin grafts d. First-degree burns 1) Are characteristically painful, red, dry, and blanch with pressure 2) Typically occur secondary to prolonged exposure to low-intensity heat or short-duration flash exposure to a heat source 3) Only a superficial layer of epidermal cells is destroyed a) They slough (peel away from healthy tissue underneath the wound) without residual scarring 4) Usually heal within 2 to 3 days e. Second-degree burns 1) Superficial partial-thickness burns a) Characterized by blisters b) Commonly caused by skin contact with the following: (1) Hot but not boiling water (2) Other hot liquids (3) Explosions producing flash burns (4) Hot grease (5) Flames c) Injury extends through the epidermis to the dermis (1) Basal layers of the skin are not destroyed (2) Skin regenerates within a few days to a week d) Edematous fluid infiltrates dermal-epidermal junction, creating blisters e) Intact blisters provide a seal that protects the wound from infection and excessive fluid loss f) Injured area is usually red, wet, and painful, and may blanch when tissue around the injury is compressed g) In the absence of infection these wounds generally heal without scarring, usually within 14 days 2) Deep partial-thickness burns a) Depth of burn involves the basal layer of the dermis

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(1) Sensation in and around the wound may be diminished because of the destruction of basal-layer nerve endings b) Depending on the degree of vascular injury, wound may appear red and wet, or white and dry c) Major complications are wound infection and subsequent infection d) If uncomplicated, injury generally heals within 3 to 4 weeks e) Skin grafting may be necessary to promote timely healing and to prevent scar tissue formation (1) Scar tissue may severely restrict joint movements and cause persistent pain and disfigurement f. Third-degree burns 1) Because the entire thickness of the epidermis and dermis is destroyed, skin grafts are necessary for timely and proper healing 2) Injury is characterized by coagulation necrosis of cells and appears pearly white, charred, or leathery 3) Definitive sign is a translucent surface in the depths of which thrombosed veins are visible 4) Eschar is present in these injuries 5) Sensation and capillary refill are absent because small blood vessels and nerve endings are destroyed a) Often results in large plasma volume loss, infection, and sepsis 6) Natural wound healing may produce contracture deformity and severe scarring 7) Surgical intervention with skin grafting is necessary to: a) Close full-thickness wounds b) Minimize complications c) Allow restoration of maximal function g. Some burn classifications include a fourth-degree burn 1) Describes a full-thickness injury that penetrates the subcutaneous tissue, muscle, fascia, periosteum, or bone 2) Usually results from incineration-type exposure and electrical burns in which heat is sufficient to destroy tissues below the skin 3. Extent and severity of burn injury a. There are several methods used to evaluate burn injury, but use of any method should never delay patient care or transport 1) Two common methods include the rule of nines and the Lund and Browder chart 2) In addition, the American Burn Association (ABA) has devised a categorization of burns to determine severity b. Rule of Nines 1) Commonly used in the prehospital and emergency department setting 2) Divides the total body surface area (TBSA) into segments that are multiples of 9% 3) Provides a rough estimate of burn injury size 4) Is most accurate for adults and for children older than 10 years of age 5) If the burn is irregularly shaped or has a scattered distribution throughout the body, the rule of nines is difficult to apply 6) In these situations, burn size can be estimated by visualizing the patients palm as an indicator of percentage (the rule of palms)The palmer surface of a patients hand (fingers and palm) equals about 1% of the TBSA
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c. Lund and Browder chart 1) A more accurate method to determine the area of burn injury a) Assigns specific numbers to each body part 2) Used to measure burns in infants and young children because it allows for developmental changes in percentages of body surface d. American Burn Association (ABA) categorization 1) Classifies burns as major, moderate, and minor 2) Considers other factors to determine burn severity a) Patients age b) Concurrent medical or surgical problems c) Complications that accompany certain burns, such as burns of: (1) Face and neck (2) Hands and feet American Burn Association Categorization Major Burn Moderate Burn 25% of the body surface 15% to 25% body or greater surface area Functionally significant No complications of involvement of hands, involvement of hands, feet, or perineum face, feet, or perineum Electrical or inhalation No electrical injury, injury inhalation injury, Concomitant injury concomitant injury, or Severe preexisting severe preexisting medical problems medical problem Minor Burn 15% or less body surface area No involvement of face, hands, feet, or perineum No electrical burns, inhalation injury, severe preexisting medical problems, or complications

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II. CHEMICAL BURN INJURY A. Introduction 1. Exposure to chemical irritants is common a. burns are result of tissue injury and destruction from necrotizing substances. b. Caustic chemicals are often present in the home and workplace 2. Three types of caustic agents are frequently associated with burn injuries a. Alkalis (strong bases with a high pH) 1) Occur in hydroxides and carbonates of sodium, potassium, ammonium, lithium, barium, and calcium 2) Commonly found in oven cleaners, household drain cleaners, fertilizers, heavy industrial cleaners, and the structural bonds of cement and concrete 3) Adheres to tissue, causing protein hydrolyses & liquefaction b. Strong Acids 1) Found in many household cleaners, such as rust removers, bathroom cleaners, and swimming pool acidifiers c. Organic compounds (chemicals that contain carbon) 1) Most organic compounds are harmless chemicals such as wood and coal 2) Organic compounds that can produce caustic injury to human tissue include phenols and creosote, and petroleum products such as gasoline 3) May be absorbed by the skin, causing serious systemic effects 3. The severity of chemical injury is related to: a. Chemical agent b. Concentration and volume of the chemical c. Duration of contact (tissue destruction may continue up to 72 hours) B. Assessment 1. Ascertain the following exposure factors during the patient history: a. Type of chemical substance 1) If the container is available and can be safely transported, it should be taken to the medical facility b. Concentration of chemical substance c. Volume of chemical substance d. Mechanism of injury (local immersion of a body part, injection, splash) e. Time of contamination f. First aid administered before EMS arrival g. Appearance (chemical burns vary in color) h. Pain C. Management 1. The treatment of chemical injuries varies little from that of thermal burns during the initial assessment. Treatment is directed at stopping the burning process 2. This can best be accomplished by the following: a. Remove all clothing, including shoes, which can trap concentrated chemicals b. Brush off powdered chemicals c. Irrigate the affected area with copious amounts of water 3. Chemical burn injury to the eyes a. Chemical exposure to the eyes irritants) may cause damage ranging from superficial inflammation to severe burns b. Patients may have: 1) Local pain 2) Visual disturbance
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3) Lacrimation 4) Edema 5) Redness of surrounding tissues c. Management includes: 1) Flushing the eyes with water by using a mild flow from a hose, IV tubing, or water from a container 2) If contact lenses are present they should be removed 3) Some agencies use nasal cannulas to irrigate both eyes simultaneously a) The cannula is placed over the bridge of the nose, with the nasal prongs pointing down toward the eyes b) The cannula is attached to an IV administration set using either normal saline solution (NS) or LR solution, and run continually into both eyes 4. Use of antidotes or neutralizing agents a. No agent has been found that is superior to water in copious amounts for treating most chemical injuries D. Specific chemical injuries 1. Petroleum a. In the absence of flame, products such as gasoline and diesel fuel can cause significant chemical burns if prolonged contact occurs b. Systemic effects from absorption of various hydrocarbons include: 1) Central nervous system (CNS) depression 2) Organ failure 3) Death c. Lead toxicity can occur if the exposure was from gasoline containing tetraethyl lead 2. Hydrofluoric acid a. One of the most corrosive materials known b. Used in industry for: 1) Cleaning fabrics and metals 2) Glass etching 3) Manufacture of silicone chips for electronic equipment c. Both the hydrogen ion and the fluoride ion are damaging to tissue d. Fluoride inhibits several chemical reactions essential to cell survival 1) Continues to penetrate and kill cells when it is neutralized by binding to calcium or magnesium e. Thus, endogenous or exogenous hydrofluoric acid can produce very deep and severe injuries 1) If large BSAs are involved, the patient may experience severe hypocalcemia and even death 2) Treatment a) Irrigate the exposed area with copious amounts of water b) Emergency department management may include subcutaneous (SQ) administration of 10% calcium gluconate solution directly into the burn site 3. Phenol (carbolic acid) a. An aromatic hydrocarbon derived from coal tar b. Widely used in industry as disinfectant in cleaning agents and in the manufacture of plastics, dyes, fertilizers, and explosives c. Skin contact can result in local tissue coagulation and systemic toxicity if the agent is absorbed d. A soft tissue injury exposure may be painless because of phenols anesthetic properties
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e. Minor exposures may cause CNS depression and dysrhythmias f. Significant exposures (10% to 15% TBSA) may require systemic support and should be carefully observed for signs of respiratory failure g. Wounds should be copiously irrigated with large volumes of water 1) After irrigation, medical direction may recommend that the wound be swabbed with a suitable solvent such as glycerol, vegetable oil, or soap and water to bind phenol and prevent its systemic absorption 4. Ammonia a. A noxious, irritating gas and strong alkali that is very soluble in water b. Extremely hazardous if introduced into the eye 1) May result in tissue necrosis and blindness 2) Patient will have swelling or spasm of the eyelids, requiring irrigation with water or a balanced saline solution for up to 24 hours c. Respiratory injury from ammonia vapors depends on the concentration and duration of exposure 1) Short-term, high-concentration exposure usually results in upperairway edema 2) Long-term, low-concentration exposure may damage the lower respiratory tract d. Initial care includes: 1) High-concentration oxygen 2) Ventilatory support as needed 3) Rapid transportation 5. Alkali metals a. Sodium and potassium are highly reactive metals that can ignite spontaneously b. Water is generally contraindicated when these metals are embedded in the skin as they react with water and produce large amounts of heat c. Physically removing the metal or covering it with oil minimizes the thermal injury

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III. ELECTRICAL BURN INJURY A. Introduction 1. Electrical injuries account for 4% to 6.5% of admissions to burn centers and are responsible for about 500 deaths each year 2. An understanding of the principles of current and the path of destruction it may produce in the body is essential for: a. Good patient care b. Personal safety at the scene of an electrocution B. Characteristics of electricity 1. Tissue damage produced by electrical current depends on six factors: a. Amperage b. Voltage c. Tissue Resistance d. Type of current e. Current pathway f. Current flow 2. Amperage a. A measure of the current flow (intensity) per unit time b. 1 ampere (amp) is a passage of 1 coulomb of charge per second past any point in a circuit 1) A coulomb is a charge transported through a conductor by a current of 1 ampere flowing for 1 second c. A 10-amp flow means that 10 coulombs of electricity are passing a point per second 3. Voltage a. A continuous force (tension) applied to any electric circuit that produces a flow of electricity. Think of amperage as flow and voltage as force b. 1 volt is the force needed to drive 1 amp of current in a circuit with 1 ohm of resistance 1) An ohm is a measure of resistance of an electrical conductor c. High-voltage electrical injuries result from contact with a source of 1000 volts or greater d. High-tension accidents commonly range from 7200 to 19,000 volts 1) May involve current with as high as 100,000 to 1,000,000 volts 4. Tissue Resistance a. Electrical resistance is composed of four factors: 1) Resistivity (capacity of material to resist current flow) 2) Size of the object pathway 3) Length of the object pathway 4) Temperature b. Resistance to the flow of electricity varies greatly within the body because various tissues have different resistance to current flow c. Tissue resistance to electrical flow is highest in bone and decreases progressively through fat, skin, muscle, blood, and nerve tissue 5. Type of current a. Two basic forms of electric current: 1) Direct current (DC) 2) Alternating current (AC) b. DC flows in one direction only 1) Frequently used in industry 2) Type of current used by batteries 3) Commonly used in electrosurgical devices and defibrillators
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4) Characterized by high amperage and low voltage c. AC reverses the direction of flow at regular intervals 1) Alterations in current direction can cause tetanic muscle contractions that may freeze the victim to the source until the current is terminated 2) Household current in the United States is generally AC and either 120 or 220 volts 3) AC is a more common cause of electrical injury 6. Current pathway a. Electricity normally flows along a continuous pathway (electrical circuit) 1) The current pathway can be somewhat unpredictable 2) Low-voltage current (less than 1000 volts) usually follows the path of least resistance 3) High-voltage current usually follows the shortest pathway b. In either case, the greater the current flow, the greater the heat generated 7. Current flow a. The pathway of the current through the body gives clues about what anatomical structures may be damaged b. If the current travels from one hand to the other it may flow across the heart, producing ventricular fibrillation or other dysrhythmias 8. Tissue injury a. Results from the conversion of electrical energy into heat- coagulation necrosis that is caused by intense heat from an electrical current b. The amount of heat produced is directly proportional to the square of the current strength multiplied by the resistance of the tissue multiplied by the duration of the current flow (Joules law) c. Therefore, injury is directly proportional to the duration of contact with the electrical source C. Types of electrical injury 1. Direct contact burns Electrical injuries may be a combination of the following types of injury both direct and flash burn a. Occur when electric current directly penetrates the resistance of the skin and underlying tissues b. Hands and wrists are common entrance sites c. Foot is a common exit site d. Skin may initially resist the flow of current 1) Continued contact with the source lessens resistance and permits increased current flow e. The greatest tissue damage occurs directly under and adjacent to the contact points and may include fat, fascia, muscle, and bone f. Although tissue destruction may be massive at entrance and exit sites, it is the area between these wounds that poses the greatest threat to the patients life 2. Arc injuries a. Occur when a person is close enough to a high-voltage source that the current between two contact points near the skin overcomes the resistance in the air 1) Passing the current flow through the air to the bystander b. Temperatures generated by these sources can be as high as 2000 to 4000 C (3632 to 7232 F) and the arc may jump as far as 10 feet 3. Flame and flash burns a. Are produced when the heat of electric current ignites a nearby combustible source b. Common injury sites include the face and eyes (Welders flash)
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c. Flash burns may also ignite a persons clothing or cause fire in the surrounding environment d. No electrical current passes through the body in this type of burn D. Effects of electrical injury 1. Electrical injuries are often unpredictable, but certain physiological effects should be anticipated 2. The skin is usually the first point of contact with electrical current a. Direct contact and passage of current may produce extensive areas of coagulation necrosis b. Entrance site is often a characteristic bulls eye wound 1) May appear dry, leathery, charred, or depressed 3. The exit wound may be ulcerated and may have an exploded appearance where areas of tissue are missing 4. Oral burns are frequently seen in children less than 2 years old a. Typically caused by chewing or sucking on low-tension electrical cord b. May be associated with injury to the tongue, palate, and face 5. Hypertension and tachycardia associated with a large release of catecholamines is a common finding in electrical injury 6. Electrical current may cause significant dysrhythmias, including ventricular fibrillation (VF) and asystole, and damage to the myocardium as it passes through the body-can be delayed 24-48 hours 7. If the patient has suffered cardiac arrest and early rescue and resuscitation can be initiated by the paramedic, success rates are high 8. Nerve tissue is an excellent conductor of electrical current a. CNS damage may result in seizure or coma with or without focal neurological findings b. Peripheral nerve injury may lead to permanent motor or sensory deficits and may be permanent c. If the current passes through the brain stem respiratory arrest or depression, or cerebral edema or hemorrhage may rapidly lead to death 9. Electrical injury can cause extensive necrosis of blood vessels a. May not be immediately evident and many cause immediate or delayed internal hemorrhage b. Arterial or venous thrombosis c. Embolism with subsequent complications 10. Damage within the extremities after electrical burn is similar to crush injury a. Severe muscle necrosis releases myoglobin b. Hemolysis releases hemoglobin, which may precipitate in the renal tubules and produce acute renal failure c. Severe muscle spasms can produce bony fractures and dislocations, even of major joints as patient may fall after the electrical shock and sustain significant skeletal trauma, including damage to the cervical spine 11. Acute renal failure is a serious complication of direct-contact electrical injuries, and affects 10% of patients a. May result from a combination of: 1) Myoglobin or hemoglobin sludging in the renal tubules 2) Disseminated intravascular coagulation (DIC) secondary to tissue damage 3) Hypovolemic shock 4) DC damage b. Prompt resuscitation and management of shock may have a positive impact on these patients
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12. Ventilation may be impaired when electrical burns produce CNS injury or chest wall dysfunction a. If the respiratory center is disrupted, hypoventilation may lead to death b. Contact with AC sources has been documented to produce respiratory arrest and death from tetany of the muscles of respiration 13. Conjunctival and corneal burns, and ruptured tympanic membranes are common in some electrical injuries a. Cataracts and hearing loss may appear as late as 1 year after the event 14. Numerous other structures may be damaged secondary to electrical injury including: a. Abdominal organs and urinary bladder b. Submucosal hemorrhage in the bowel c. Various forms of ulceration 15. Fractures of long bones & vertebra 16. Each patient requires a thorough assessment and a high degree of suspicion for associated trauma E. Assessment and management 1. Begin by ensuring scene safety for rescuers or bystanders 2. If the patient is still in contact with the electrical source, contact appropriate personnel before approaching the patient a. Electric company b. Fire department c. Other specially trained personnel 3. Once the scene is safe, patient care can begin 4. Initial assessment a. Proceed as for all other trauma patients b. Immobilize the cervical spine c. If the patient is not breathing, provide assisted ventilation immediately 1) Intubation should be performed as soon as possible because apnea may persist for lengthy periods d. For the breathing patient, maintain a patent airway and support with supplemental high-concentration oxygen e. If the patient is in cardiac arrest, resuscitation efforts should be implemented according to protocol 5. Obtain a history if possible a. Patients chief complaint (e.g., injury, disorientation) b. Source, voltage, and amperage of the electrical injury c. Duration of contact d. Level of consciousness before and after the injury e. Past significant medical history 6. Physical examination a. Be particularly thorough to search for: 1) Entrance and exit wounds 2) Associated trauma caused by tetany or a fall b. Remove all clothing and jewelry c. Look between the patients fingers and toes examining for sites of entry or exit d. Carefully assess and document distal pulses, motor function, and sensation in all extremities e. Cover entrance and exit wounds with sterile dressings f. Manage associated trauma appropriately 7. Frequent reassessment is necessary because of the progressive nature of electrical injury a. ECG monitoring should be implemented at the scene and continued during patient transport
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b. Dysrhythmias are common; some can be lethal 8. Management a. Early fluid resuscitation is critical in managing patients with severe electrical injury to prevent hypovolemia and subsequent renal failure b. Establish two large-bore IV lines in an extremity without entry or exit wounds 1) The fluid of choice is usually LR or NS without glucose 2) Flow rate should be determined by the patients clinical status c. Emergency department or interhospital transfer care may include: 1) Regulation of IV infusion rates to maintain a urine output of 75 to 100 ml/hr a) Decreases the potential for renal damage caused by myoglobin 2) Administration of sodium bicarbonate to maintain an alkaline urine a) Increases the solubility of hemoglobin and myoglobin, minimizing the incidence of renal failure d. Apply dry, sterile dressings to entry and exit wounds

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IV. RADIATION BURN/EXPOSURE A. Introduction 1. Most radiation accidents involve sealed radioactive sources used in industrial radiography and nondestructive testing a. Victims of these types of accidents rarely require emergency care B. Characteristics of radioactive particles 1. Radioactive particles generally are classified into three types: alpha, beta, and gamma 2. Alpha particles a. Large b. Travel only a few millimeters c. Have minimal penetrating ability d. May be stopped by paper, clothing, or skin e. Considered the least dangerous external radiation source f. May enter the body through inhalation, ingestion, or absorption 1) Can damage internal organs and interfere with chemical functions 2) Considered the most dangerous form of internal radiation exposure g. Require full protective clothing, including positive pressure self-contained breathing apparatus 3. Beta particles a. 1/7000 the size of alpha particles b. Have more energy and penetrating power c. Can penetrate subcutaneous tissue 1) Usually enter the body through damaged skin, ingestion, inhalation d. Require full protective clothing, including positive pressure SCBA 4. Gamma rays and x-rays a. The most dangerous forms of penetrating radiation 1) Gamma rays have 10,000 times the penetrating power of alpha particles; 100 times that of beta particles b. Protective clothing will not stop gamma rays 1) Require lead shields for protection c. May produce both internal and external hazards 1) Localized skin burns 2) Extensive internal damage C. Harmful effects from radiation exposure 1. Nonionizing radiation a. Not usually considered dangerous b. Radio waves and microwaves 2. Ionizing radiation a. Produced by: 1) Nuclear weapons 2) Reactors 3) Radioactive material 4) X-ray machines b. Poses a threat to rescue personnel 3. Measurements of radiation a. Roentgens 1) The amount of emitted radiation produced in the air by gamma or xradiation b. Radiation absorbed dose (rad) 1) Measurement of both the amount of ionized radiation being emitted and the amount absorbed and active within body tissue
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c. Roentgen equivalent man (rem) 1) Used to assess the biological effects of the different types of radiation 2) For emergency purposes, assume that 1 roentgen=1 rad=1 rem d. Radiation doses 1) Persons routinely exposed must have continuous monitoring 2) Doses less than 100 rem usually do not cause significant acute problems 3) Doses from 100 to 200 rem may cause symptoms, but are not lifethreatening 4) Doses of 200 rem cause nausea, vomiting, and diarrhea within 2 to 4 hours 5) After an exposure of 450 rem, 50% mortality can be expected within 30 days without medical care D. Emergency response to radiation accidents 1. If advised that radioactive materials are present at an emergency scene, approach the site with caution and do not enter the scene until it has been secured by proper authorities a. Rescue personnel, emergency vehicles, and the command post should be positioned 200 to 300 feet upwind of the site b. Emergency workers should not eat, drink, or smoke at the accident site or in any rescue vehicle 2. Appropriate local authorities should be contacted (state radiological health office, local specialists), and medical direction should be notified 3. Protective clothing suitable for other hazardous material releases should be worn by all emergency workers a. Dose meters should be available for all rescue personnel b. SCBAs should be used if fire, smoke, or gas is present 4. Personal protection from radiation a. Four factors for basic radiation protection 1) Time a) The less time spent in the radiation field, the less the radiation exposure b )Use a rotating team approach to minimize individual radiation exposure 2) Distance a) The further a person is from the source, the lower the radiation dose b) Even moving several feet away from a radioactive source greatly reduces the level of exposure 3) Shielding a) The denser the material, the greater the protection b) If adequate shielding is not available, use the time and distance factors to reduce exposure 4) Quantity a) Limit the amount of radioactive material in a specific area to lessen exposure b) Remove and bag contaminated clothing and other items c) Move containers of radioactive material from the area E. Emergency care for victims of radiation accidents 1. Patients who have been irradiated are not radioactive 2. Follow protocol for removing radioactive material from a patients clothing, skin, or open wounds 3. Aside from removing contaminants, treat patients following trauma guidelines
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a. Control all external bleeding b. Immobilize the spine if indicated c. Cover open wounds d. Immobilize fractures 4. Move the patient from the radiation source 5. Do not delay lifesaving care for patient transfer or decontamination 6. IV fluid replacement should be initiated if indicated, using strict aseptic technique F. Radiation decontamination procedures 1. Radiation emergencies may be defined as either: a. Clean, meaning the patient was exposed but not contaminated b. Dirty, meaning the patient was contaminated 2. Only properly trained personnel (e.g., Hazmat teams and qualified county, state, or federal health department personnel) should attempt to decontaminate radiation victims

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V. PSYCHOSOCIAL ISSUES A. Introduction 1. A burn injury is a frightening & potentially life-changing event for patients and families. Because of this loss/change in their lives, they can often face many difficult emotions at varying stages after the injury. Intervention must start initially. 2. Caring for burn patients can cause extreme stress on clinical patient care staff. Critical Stress Defusing/Debriefing sessions must be made available early and often for staff. 3. Social Work and clinical psychology provide assessment and intervention to burn patients from a wide range of psychosocial backgrounds. B. Considerations 1. One implication of the increasing survival of patients with a severe burn injury is the need for psychosocial support for patients and their families/significant others. Psychosocial assessment and treatment begins during the initial phase of treatment and is continuous throughout as patients and families needs change at different stages of recovery. 2. Shock and disbelief are early emotional responses to traumatic events. For most individuals, cognition will be greatly diminished and the ability to reason and problem solve will become impaired. Anger can also be a component of the early emotional response, as well as attributing blame fault or feeling guilt. 3. The impact of the burn can result in permanent disability and disfigurement. Given the nature of burn injury and its treatment there are many stressors that may trigger psychological problems, particularly those associated with anxiety and depression. 4. Assessment and management of emotional distress, pain-coping strategies, grief and bereavement, survival and mental health issues, and dealing with changes in body image, are necessary in the case of the patient with a severe burn injury, in order to ensure adequate compliance with treatment initially, throughout, and during rehabilitation goals. 5. General information should be provided to the family of a burn patient prior to their initial encounter with that patient. Answer their questions honestly and provide emotional support, recognizing the psychological reactions to trauma. 6. Introduce the personnel who will be caring for the patient, reassure that measures are being taken to provide for the patients comfort, identify a family spokesperson and clarify any information provided from the medical team as it becomes necessary. 7. DNR orders, religious customs, legal issues may have to be addressed and resolved early.

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