Environmental injuries

J. Málek

©

Burns

Functions of the skin•Maintain body temperature

•Protection against infection

•Prevention of fluid loss

•Excretion (sweat)

•Sensory function

•Individual identity

Assessment of burn injury

• Mechanism• Circumstances• Extent• Localisation• Depth• Other injuries• Age + complicating diseases• First aid• Transport

Mechanism of injury• Heat transmission - contact - radiation• Dry burn - open space - limited space (inhalation)• Scald - liquids - steam• Chemical burns - contact, fumes• Electric current - low/high voltage,

lightning• Radiation burn

Circumstances

before and after injury can modify the otcome

• excercise, fear, running

Extent of injury• Rule“9“ in adults• Rule „palm“= 1% in children

• Extent is frequently more important than the depth

• Sever burns• Less than 2 years ≥ 5 %• 2-10 y. ≥ 10%• 10-15 y. ≥ 15%• Adults ≥ 20%

• Localisation: much lower extent in case of burns of face, hands, legs, airways, genitals

• Critical burns

• < 2 years ≥ 15%

• 2-10 y. ≥ 20%

• 10-15 y. ≥ 30%

• Lower extent in case of burns of face, neck, airways, electric current passage and other injuries or complicating deseases

Depth of injury

• Old classification - 3 classes– 1st degree: redness, swelling, pain– 2nd degree: blisters– 3rd degree: full thickness skin loss

Depth of injury• New classification - 2 classes• Superficial - partial damage or skin loss with preserved

hair follicle and sweat glands - spontaneous epitelisation possible

• Deep - full thickness skin loss - only surgical therapy possible

• Dg aid - capillary return test - sensitivity

Minor burns • Cooling (not ice!) • Remove jewels, rings etc.• Cover with sterile dressing • Common analgesics - ibuprofen, ASA,

paracetamol• Medical treatment:

– extent > 3%)– infants, babies, very old people– localisation: genitals, buttocks, hands, legs

• Never: – break blisters– apply ointment or fat– apply adhesive dressings to the skin

Major burns• Remove the victim, stop the burning• Help the victim to lie down• Call EMS• Cool with cold water only face and peripheral

parts of the body• Cover the injured area with a sterile dressing• Never

– overcool the casualty (cooling the whole body)– remove anything sticking to the burn– burst blisters– apply lotions, ointment, fat etc.– give anything to eat and drink

Warning signs of inhalational injury

• Burning or explosion in a closed space• Burns of head, neck and front part of the thorax• Burned nasal hairs• Hoarseness• Cough• Black sputum• Hyperproducion of phlegm• Inspiratory (laryngospasm) or expiratory

(bronchospasm) stridor

First aid in burns to the airway• Call EMS• In conscious

– prefer sitting position– offer ice– cool face and neck– keep the victim calm– regularly check breathing

• In unconscious– cool face and neck– use recovery or antishock position– be prepared for CPR

HyperthermiaSunstroke

Hyperthermia

• Prolonged exposure to heat, failure of thermoregulation, Ecstasy

• Signs: dizziness, cramps, restlessness, confusion, unconsciousness, hot skin, rapid pulse, BT>40 deg.

• First aid: remove to a cold place, cooling, in conscious: mineral water, rehydratation drinks in unconscious: monitor vital signs

Sunstroke

• Combination of hyperthermia and direct effect on CNS

• Signs: Headache, dizziness, discomfort, confusion, nausea, vomiting

• First aid: move a victim to a shadow area, cooling, frequent sips of cold drinks, paracetamol

Frostbite

Frostbite

• Usually fingers and toes, ears, nose, chin, cheeks

• Signs– 1st degree – skin is pale or cyanotic, pins and

needles during warming – 2nd degree – white or grey soft tissue, pain,

blisters after warming – 3rd degree: wax-like appearence, hard, loss

of sensibility, after rewarming black

First aid

• Move the casualty into warm• Place the affected part into warm water

(40 deg.)• Cover with sterile dressing• Never

– put the injured part near direct heat– attempt to thaw if there is a danger of

refreezing– allow the casualty to smoke

Hypothermia

Mild hypothermia

• Body temperature 34 - 36,5 oC – Shivering, excitation – Pain in extremities – pale, livid skin – tachycardia

• First aid:– transport to the dry, protected space (leeward)– change clothes– active, passive movement– warm sweet drink

• No spirits!!

– Slow rewarming: blankets, warm bath, body heat

Medium hypothermia

• Body temperature 30-34 oC – pain disappears – bradycardia, arrhytmias – irregular breathing– apathy, irrational behavior

• First aid as in mild hypothermia, but +:– nothing to eat and drink– no warm bath– EMS– Be prepared to CPR

Severe hypothermia

• Body temperature 27-30 oC – deep unconsciousness, broad pupils – weak pulse – slow and ireregular breathing

• First aid– protect from heat loss– no movement– be prepared for modified CPR

Critical hypothermia

• Body temperature < 27 oC – Coma – respiratory and circulatory arrest

• bellow 28 oC ventricular fibrillation

• First aid – prevent heat loss– CPR

• treatment - extracorporeal circulation

Electric current injury

Low-voltage current (<1000 V)

• Switch off the current, brake the contact with the source

• Check vital functions– CAVE: ventricular fibrillation

• Treat burns

• Treat other injuries

High-voltage injury (>1000 V)

• Call 112 to inform the rescue service

• Stay in a safe distance until you are officiall informed thet the current has been switched of

• After extrincion check for vital functions

• Treat burns

• Treat othe injuries – e.g. fixation of fractures, treatment of pneumothorax

• Antishock therapy

Lightning strike

• Circumstances: storm, position of a victim, burns, failure of vital functions

• Therapy: same as in high-voltage injury

Chemical burns

First aid

• Remove clothes (do not move it over unaffected area!!!)

• Flood with water for at least 30 min (neutralization)

• Apply sterile dressing

• Antishock therapy

• Intoxication???

Acids and alkalis

• Flood with water for 20 min., then you can neutralise– acids = alkali soap or bicarbonate 6 - 8%– alkali = diluted acetic acid or citric acid

• Other as in burns

Chemical burns of the eye

• Flood with large amount of water at least 30 min, use force to open the eyelids in necessary

• Apply sterile dressing on both eyes

Chemical burns in the mouth

• Flooding with water

• Check breathing

Chemical burns of oesophagus and stomach

• Signs– pain, nausea, cramps, shock

• Never induce vomiting

• Put the victim to a relief position

• Control vital functions

• Antishock therapy

• EMS

Drowning

Drowning • Dry – reflex spasm of vocal cords, no inspiration

of water (cca 15%)• Inspiration of water

– Fresh water• Quickly absorbed to circulation – haemolysis, brain oedema • Sea water - hyperosmolality – water crosses from capillaries

to alveoli

• NEVER TRY TO RESCUE A DRAWNING, UNLESS YOU ARE A GOOD SWIMMER

• Other mechanisms of injury: hypothermia (prolongs surviving, but BT < 28 oC – risk of VF, trauma, „vagal death“

Drowning

• Start artificial ventilation as soon as possible• NEVER try to remove water from lungs – this

postpones start of CPR • Clean mouth, control ventilation • Start CPR if necessary, ventilation first!!!• If spontaneous breathing is present, put a victim

to recovery position• Prevent or treat hypothermia• Always call EMS – risk of ARDS

Animal and insect bites

Animal bite

• Crushing and tearing

• Risk of infection, bleeding

• First aid– Clean with soap (rabies prevention)– Disinfection and sterile dressing– Try to find a keeper of the animal – Definitive treatment by a doctor (event. Plus

vaccination)

Rabies • Viral infection (rhabdovir)• Incubatiion period 3 - 4 weeks, but can be shorter or longer

(several months) • Transmission by saliva, rabies virus spreads through the

nerves to the spinal cord and brain. After uptake into peripheral nerves, rabies virus is transported to the central nervous system.

• The first symptoms of rabies may be nonspecific flu-like signs — malaise, fever, or headache, which may last for days. There may be discomfort or paresthesia at the site of exposure (bite), progressing within days to symptoms of cerebral dysfunction, anxiety, confusion, agitation, progressing to delirium, abnormal behavior, hallucinations, and insomnia. Death results from paralysis of peripheral and cranial nerves

Postexposure anti-rabies vaccination usually includes administration of both passive antibody and vaccine.

Insect sting (bee, bumblebee, wasp, hornet)

• Allergic reaction

• Toxic reaction (multiple stings in babies), oedema in the airway

• First aid– Remove the rest of a bee sting– Disinfect– Cooling (nebo mýdlo, octan, cibule,..)– EPIpen

Ticks• Remove intact by a tweezer

and také for analysis• Disifection• Risks

– Viral encephalitis: - meingitis 1 – 2 weeks post exposure (headache, stiffness of neck, fever, disturbances of consciousness

– Lymes borreliosis- slowly expanding pink or reddish rash (3-10 d.) „flu-like“ symptoms (2-4 w.), neural infection (weeks post exposure)

Other insects (mosquito, horse-fly etc.)

• Cooling, onion, ammonium, vinegar???

• Fenistil gel or other antihistaminic

• Systemic reaction– Antihistaminic p.o.– EPIpen

Allergy

Degranulation processes 1 - antigen; 2 - IgE antibody; 3 - FcεRI receptor; 4 - preformed mediators (histamine, proteases, chemokines, heparine); 5 - granules; 6 - mast cell; 7 - newly formed mediators (prostaglandins, leukotrienes, thromboxanes)

Allergic reactions

• Urticaria

• Conjunctivitis and hay fever

• Swelling

• Nausea and vomiting

• Asthma

• Anaphylactic shock

Food allergy• Types

– Skin reactions• Eczema, urtica, swelling

– Airway reactions• Hay fever, dyspnoea

– GIT reactions• Nausea, vomiting, abdominal pain

• Allergen – anything– Milk, egg white, fish, fruit de mere, nuts,

strawberry…….

• Prevention, therapy

Delayed hypersensitivity – Contact eczema

• Signs– rush– Wet skin reaction– Itching

• Therapy– Allergy testing – Avoidance of allergens– Antihistaminic– Local corticosteroids

Solar eczema

• Symptoms– Skin reaction, urticaria, swelling, erythema– Headache, fatigue, malaise

• Therapy– Avoidance of sun-bath– High protection solar creams– Betacaroten

• effect ???