Basal Cell Carcinoma Malignant Tumour Biology Essay



Can present in many different forms. Appears as a shiny "pearly nodule and later breaks down, becoming an ulcer with irregular edges, commonly called a rodent ulcer". (Waugh et el, 2006)

Burns- The skin has two layers:-epidermis and dermis which overlaying subcutaneous fatty tissue. There are different types of burn.

Superficial Burn- Only the epidermis is affected. Pain is experienced by the individual due to air exposure of the nerve endings. Blisters are rarely present and the skin is red and, when touched, the colour will blanch and return(Caroline, 2007). This will heal within 3-7 days.

Partial Thickness Burn- Both the epidermis and dermis layers are affected. Partial thickness burns can be split into two separate categories, superficial and deep.

Superficial Partial-Thickness Burns again have reddening of the skin that blanches on touch."Usually there are blisters or moisture present, the patient may experience extreme pain and hair follicles remain intact" (Caroline, 2007)

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Deep Partial-Thickness Burn effect a greater depth of the dermis layer. In contrast to Superficial partial-thickness burns "hair follicle and sweat and sebaceous glands are damaged".( Caroline, 2007)

Full-Thickness Burn- Both the main layers of skin are destroyed/damaged and depth of burn also affects the subcutaneous fatty layer.

Characteristics of this deep burn are white skin and pale, brown and leathery or charred. Escher (thick scab) will eventually form. Both the capillaries and sensory nerves are destroyed in the full thickness section. This results in no capillary refill or sensation of pain to the effected area respectably. Despite this "patients usually have mixed depths of burn and will experience significant pain in the areas surrounding the full-thickness burns" (Caroline, 2007)


Heat Stroke- the absence of sweating, with hot red or flushed dry skin

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Question 2


Sympathomimetic Drug- Is a substance that mimics the effect of the sympathetic nervous system. Sympathoimetic drugs stimulate the postganglionic sympathetic terminal. It does this by either blocking breakdown and reuptake, directly activating postsynaptic receptors or stimulates production and release of catecholamines.

Catechlomines- These are sympathomimetic hormones released by the adrenal glands and form part of the sympathetic nervous system. These are released when the body experiences emotions such as fear and are also known as "flight or fight" hormones

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One chemical bond that is present is a covalent bond represented by the straight lines coming down from the top of the diagram. "When a covalent bond forms, two or more atoms share electrons rather than gaining or loosing them"( Tortora et el, 2006). Covalent bonds are the most numerous in the boy and the strongest '(Unit 3.2, p.37) These bonds come in three main types. These include single covalent bonds (two atoms share one electron pair), double covalent bonds (two atoms share two pairs of electrons) and triple covalent bonds (two atoms share three pairs of electrons)

Hydrogen bonds are also present. "These are depicted by the dotted lines between the electronegative elements, X, with the partial negative charge an the hydrogen of the left hand hydroxyl" '(Unit 3.3, p.39) "A hydrogen bond forms when a hydrogen atom with partial positive charge attracts the partial negative charge of neighbouring electronegative atoms, more often larger oxygen or nitrogen atom"( Tortora et el, 2006) They do not share electrons like covalent bonds instead attracting oppositely charge parts of molecules. Hydrogen bonds are weaker than covalent ionic bonds but stronger than a Van der Waals interaction.

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Its adrenaline/epinephrine

Question 3


Five manifestations of hypoxic hypercapnia include

Raised blood pressure

Full pulse

Flushed skin


Confusion/hypoxic fits


Masseter muscle spasm results in forceful jaw closure and can caused by a number of diseases including Tetanus, complication of radiation therapy, cerebral irritation, trauma and strokes.

Its alternative name is Trismus.


Invasive procedure- Following guideline indications I would perform a jaw-thrust manoeuvre to open the patients airway. The technique is to "place your fingers behind the angle of the jaw and lifting the jaw forward...the jaw is displaced forward at the mandibular angle"(Caroline, 2007)

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Adjunct- There seems to be some disagreement as to what adjunct is best to use under the circumstances depending what text is referenced. Due to this I feel it would be unfair and irresponsible to state just one procedure.

Some literature states that nasopharyngeal airways are" particularly useful in masseter spasm" '( Unit 1.3.2, p.116). However this poses a couple of questions. Firstly this adjunct is also available to ambulance technicians and not exclusively a paramedic procedure. Secondly under ambulance guidelines and stated in Nancy Caroline this is a contraindication if facial/skull fracture or recurring nose bleeds are present or suspected. These injuries must always be suspected with a major head injury?

The alternative is the needle cricothyroidotomy. This is a more complicated procedure in which "a cannula is inserted through the cricothyroid membrane"(Caroline, 2007) establishing an airway. This is not only a paramedic skill unavailable to ambulance technicians but also indicated under ambulance guidelines.

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Question 4




Newton's first law relates to the subject of inertia and can easily be applied to understanding what occurs during road traffic collisions.

A car is travelling at a speed of 50 mph and has a driver and a passenger. The driver is wearing his seatbelt where as the passenger does not.

A steady speed can be maintained using motorised propulsion. Both the car and two people inside are travelling 50mph. If this artificial propulsion was taken away under Newton's first law the vehicle would continue in the same direction until gradually being slowed. The speed and direction (velocity) of the two people in the vehicle would be proportionally to that of the vehicles, as will the passengers deceleration.

Now imagine the same scenario but instead the vehicle collides with a solid object/mass. The vehicle is suddenly stopped. The driver continues to travel n the same direction at 50 mph until they are stopped by their seat belt. They may receive injury/trauma from the down and under or up and over pathway.

The passenger however has nothing to stop them. They continue at the same velocity either bulls eyeing the windscreen or going through it completely. The passenger will continue to travel at this velocity until either colliding with a solid mass/ object themselves or being slowed by gravity, wind resistance and friction.

This part of the law can also be applied to the angle of two vehicles colliding and the following impact to the passengers. There are five types of impact patterns; Frontal/head-on, rear impact, lateral/side-on, rotational and rollover.

Another example can be applied to less dramatic RTC. A vehicle travelling in a straight line collides with another vehicle that is stationary. If the stationary vehicle has their handbrake on both parties may sustained greater injuries than if the hand break was off. This is due to the greater resistance to movement (inertia) the stationary vehicle poses.

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The Law of Conservation Energy states that energy cannot be destroyed or created. Instead this closed system of energy can be converted into varying different forms including chemical, kinetic, thermal, gravitational and mechanical.

The formula for this is

An object in motion causes energy to be converted to kinetic energy. An objects kinetic energy is determined by its mass and more so by the velocity it travels. As an object in motion that is suddenly forced to stop converts this kinetic energy into other forms of mechanical energy through energy dissipation.

This can be related to both blunt and penetrating trauma. Let's use a two car head on collision.

Both cars have a mass and are travelling at a certain velocity creating kinetic energy. As both vehicles collide they are forced to suddenly stop. This kinetic energy cannot be destroyed so must there for be altered to a new form of energy. This energy convert to thermal (friction) and mechanical energy (crumple zones of a car) while still travelling in same direction as the cars motion..

The remaining energy that has not been converted will travel to the object with the less mass and density which tends to be the passenger. This causes mechanical trauma to the patient either through fractured bones or internal organ injury.

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Question 5


Enzymes are mainly protein molecules which catalyze specific reactions with great efficiency in the living body and may consist of two parts, apoenzyme and a confactor.


Enzyme activity is affected by substrate type, tempurature, PH and substrate concentration

Temperature- "This optimal temperature is usually around human body temperature (37.5 oC) for the enzymes in human cells".( Royal Society of Chemistry, 2009).

"A ten degree Centigrade rise in temperature will increase the activity of most enzymes by 50 to 100% "(Worthington-Biochemical Corporation, 2009) However, if the temperature increases above 37.5 enzyme structure begins to denature as the increased kinetic energy (cause by heating) break down molecular bonds.

If the temperature decreases kinetic energy is lost from reacting molecules. Less kinetic energy means less movement of the reacting molecules and hence the chances of a successful collision are reduced.

PH- "The optimum pH value will vary greatly from one enzyme to another :"( Worthington-Biochemical Corporation, 2009). These pH levels can vary from as low as 4.0 to as high as 8.7. "Changes in pH can change the shape of the enzyme and, therefore, its effectiveness." (Royal Society of Chemistry, 2009).

Substrate concentration- "The rate of an enzyme-catalysed reaction depends on the concentrations of enzyme and substrate, as the concentration of either is increased the rate of reaction increases". (Royal Society of Chemistry, 2009)

This, however, will not continue in defiantly. There is a point where increased substrate concentration will not cause any significant change of reaction rate. Very much like a sponge in water, there is only so much the sponge can take up.. Enzyme molecules active site can also become saturated in this way and "the enzyme/substrate complex has to dissociate before the active sites are free to accommodate more substrate" (Royal Society of Chemistry, 2009).

Substrate type- The type of substrate can effect enzyme reaction. Some substrates can "alter the catalytic action of the enzyme and consequently slow down, or in some cases, stop catalysis" (Worthington-Biochemical Corporation, 2009). These are known as inhibitors.

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Enzymes are essential for life. They aid metabolism, digestion and allow key reactions to occur throughout the body. Without them the living body would not function. With this in mind as a clinician the maintenance of the optimum environment for enzymes to work is essential.

The environment the clinician must maintain is their patient's body. Stated in question (i) where the physiological conditions that effect enzyme activity in the body. With this in mind I will state how the clinician could maintain these factors.

Temperature- As stated the optimum temperature for enzyme activity is 37.5c. This is normal body temperature. The aim should be to maintain your patient's temperature at 37.5c. The patient's temperature is either lower or higher than this action may be taken to resolve the imbalance. For example wet clothing may be removed and the body warmed slowly with blankets and hot fluid (hypothermia) or clothes removed and the body gradually replenished with fluid (hyperthermia). This can be monitored by taking the patients tempura tire using a thermometer.

Ph- Change in the patient's body can be due to a number of reasons. PH can decrease (become more acidic) if the patient is accumulating too high levels of C02(e.g. dyspnoea). This may be directly overcome by supplying them with oxygen. PH may be altered due to other reasons such as diet. Indirect aid can be given to the patient through dietary advice. The optimum pH for our blood and body tissues is about 7.2

Substrate type and level- As a clinician the type and amount of drug given to the patient must be correct.

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Question 6


The definition of idiosyncratic is:-

1. A structural or behavioural characteristic peculiar to an individual or group.

2. An unusual individual reaction to food or a drug.

(, 2009)

The World Health Organisation, defines an adverse drug reaction as: "Any response to a drug which is noxious and unintended and that occurs at doses used in man for prophylaxis, diagnosis or therapy"(NHS Education for Scotland, 2009).

In reference to drug research idiosyncratic variables are adverse drug reactions that occur rarely and unpredictably amongst the population. These reactions are also known as type B reactions. These often occur when too little research of a new drugs side effects have been conducted before release into the population for consumption.

"Type A (augmented) reactions result from an exaggeration of a drug's normal pharmacological actions when given at the usual therapeutic dose and are normally dose-dependent"(MHRA,2009)This can be seen in overdoses of heroin. One of heroine's effects is to reduce respiration rate. An overdose (or Type A reaction) would result in respiratory arrest.

"Type B (idiosyncratic) reactions are novel responses that are not expected from the known pharmacological actions of the drug"(MHRA,2009). These include Anaphylaxis with penicillin and skin rashes with antibiotics. Characteristics of these reactions are that they are Unpredictable, Rarely dose dependent, have a Low morbidity, have a high mortality and respond to drug withdrawal.

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The yellow card scheme was introduced so the likes of doctors, dentists, coroners and nurses among others could report any drug currently on the market/in medical use were having adveres drug reactions (ADR's).An ADR is an "unwanted or harmful reaction experienced following the administration of a drug or combination of drugs under normal conditions of use and which is suspected to be related to the drug"( Royal Society of Chemistry, 2009)

Originally open testing was used to reduce ADR's. both the researcher and the patient know what drug is being tested and who has taken it. This had it's limitations, including.

The placebo affect.


Observer bias

Self-limiting illness.

The Hawthorne effect

Double blind trials attempt to eliminate these biases. Not all patients actually take the drug and instead take a placebo pill(fake). None of the researchers or the patient knows who is on the real drug and who is on the placebo. To ensure this anonymous the treatment they receive is coded. Only at the end of the trial is it revealed what patient was on the real medication and who was on the placebo.

ADR's are still reported despite theses trials. There could be a number of explanations for this.

Sample size is too small for accurate result. The number of the individuals the drug is tested on only needs to be in its thousands where the drug may be used on millions on the market

Patients under special circumstances may not have been involve in the trial(i.e. pregnant)

The trial drug may have adverse reaction when used in conjunction with their forms of medication

Long term use of a rug may reveal ADR's not observed in a relatively short trials.

Bypass may still be present in some form(i.e. Hawthorne effect)

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Yes it would, presuming the null hypothesis was true. P<0.05 basically means the drug shows 95% of working (relive minor symptoms). Ideally the P value should indicate 99% chance of success (P<0.01) to give the statement more credibility. In most scientific studies anything in the ranges of <0.05 and <0.01 is in the accepted range

Question 7


The formula used is

Initially units must be converted to make the formula work

8 stone=50.8 Kg

30 feet=9.14m

Using the formula..

Eg =50.8x 9.8 x 9.14= 4550.2576

Eg = 4550.2576



The formula used is

Initially units must be converted to make the formula work

2.5 m tonnes=2500Kg

30mph=13.4 metres per second


Ek= 0.5x2500x13.4x13.4=224450

Ek=224450 j


Initially units must be converted to make the formula work

2.5 m tonnes=2500Kg

40mph= 17.8 metres per second



Ek=396050 j

To compare the two varying velocities the difference between the two results must be calculated


At 40miles per hour an extra 171600 j is dispersed compare to 30mph

Question 8


The cell membrane is best described as the fluid mosaic model its "molecular arrangement of the plasma membrane resembles an ever-moving sea of fluids lipids that contain a mosaic of many different proteins"( Tortora et el, 2006). Lipids are amphupathic meaning they have polar and non-polar parts. The outer layers consist of the polar head (hydrophilic) and the inner of the nonpolar fatty acid tails (hydrophobic)

The fact that the cell membrane is mainly mad up of amphipatic lipids gives it the property of selective permeability. This means" it is not a total barrier, instead exerting relatively strict controls over which substances can pass"'(Unit 2.2, p.60)

Lipids therefor have little difficulty breaking this barrier. They have few covalent bonds present. They can easily pass through this layer as they are soluble, in other words they can dissolve into the membrane layer and pass into the cell.

However, their cell membrane is a barrier to charged or polar substances such as ions, prohibiting their entrance and exit from the cell. This is due to the non-polar fatty tails and the fact "polar substances are not very fat soluble"( Unit 2.2, p.60). They are water loving unlike lipids.

There are a number of ways these charged ions can pass through this barrier. Some ions (e.g. urea) move through small gaps of the fatty non-polar tails that randomly appear.

Others are transported through ion channels by facilitated diffusion. Ion channels are protein structures in the membrane that fill with water. As ions are polar water loving substances they can dissolve and pass through in these channels.

"Certain large proteins such as glucose bind to and are carried by special carrier proteins in the cell membrane which is known as active transport"( Unit 2.4, p.61)

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Active transport. "This is an active process because energy is required for carried proteins to move solute across the membrane against concentration gradient"( Tortora et el, 2006) There are two types of active transport

Primary Active Transport- "energy derived from hydrolysis of ATP changes the shape of carrier protein, which pumps a substance across a plasma membrane against its concentration gradient"( Tortora et el, 2006) Often the carrier proteins involved are also known as pumps.

"All cells have thousands of soium-pottasium pumps in their plasma membrane"( Tortora et el, 2006) The most common primary active transport mechanism brings potassium ions into the cell while expels sodium ions.

Passive transport will leak sodium and potassium back across the cell membrane. Due to this these pumps must constantly operate in order to keep cell ion levels at equilibrium in the cytosol.

Primary ion transport involves Mitchell's chemiosmotic reactions. These generate ion currents while also utilizing them for chemosynthesis

Secondary Active Transport-"In secondary active transport, a carrier protein simultaneously binds sodium ions an noher substance and then changes its shape so that both substances cross the membrane at the same time"( Tortora et el, 2006). Symporters is the name given when these two substances move in the same direction. Antiporters are the name given when two substances move in the opposite directions across the membrane.

This form of active transport can occur by indirectly using energy created by primary active transport. Primary active transport involves the continuous operation of sodium pumps. This allows ions to store energy (potential energy). This potential energy can be converted to kinetic energy very much in the same way as water stored behind a dam wall can be converted(i.e. for electricity). It is this energy which powers the process of secondary active transport.

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Burns- The skin has two layers:-epidermis and dermis which overlaying subcutaneous fatty tissue. There are different types of burn.

Superficial Burn- Only the epidermis is affected. Pain is experienced by the individual due to air exposure of the nerve endings. Blisters are rarely present and the skin is red and, when touched, the colour will blanch and return(Caroline, 2007). This will heal within 3-7 days.

Partial Thickness Burn- Both the epidermis and dermis layers are affected. Partial thickness burns can be split into two separate categories, superficial and deep.

Superficial partial-thickness burns again have reddening of the skin that blanches ontouch."usually there are blisters or moisture present, the patient may experience extreme pain and hair follicles remain intact"( Caroline, 2007)

Deep partial-thickness burn effect a greater depth of the dermis layer. In contrast to Superficial partial-thickness burns "hair follicle and sweat and sebaceous glands"( Caroline, 2007) are damaged.

Full-Thickness Burn- Both the main layers of skin are destroyed/damaged and depth of burn also affects the subcutaneous fatty layer.

Characteristics of this deep burn are "white skin and pale, brown and leathery or charred. Escher (thick scab) will eventually form Both the capillaries and sensory nerves are destroyed in the full thickness section. This results in no capillary refill or sensation of pain to the effected area respectably. Despite this "patients usually have mixed depths of burn and will experience significant pain in the areas surrounding the full-thickness burns" (Caroline, 2007)


A typical serious burn could refer to the mentioned deep partial thickness burn or more likely a full thickness burn in which the epidermis, dermis and overlaying subcutaneous fatty tissue are all damaged or completely destroyed.

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The area burnt is more significant than the depth of burn (Ambulance Service, 2008).There are a number of ways the total body surface area (TBSA) of burn can be calculated.

The rule of nines divides the body into segments of 9%. For example in an adult patient the head(9%), each arm(9%) the posterior torso is considered two flanks(18%) anterior torso is the same(18%) back and front of each leg is considered(18%) and groin(1%). When calculated the body as a whole equals 100%.

The rule of palm considers the patients own palm (excluding fingers) to represent 1% of their TBSA. Probably the least accurate of the techniques but "is helpful when the burn covers less than 10% of the body surface area or is irregularly shaped"(Caroline, 2007)

The most detailed calculation is the Lund and Browder chart. Similar to the rule of nines but sections the body in more detail. This allows a higher level of accuracy of TBSA but due its complex nature "is seldom used prehospital"( Caroline, 2007)

Considering the patient in the scenario is prehospital and burns cover more than 10% I will use the rule of 9's to calculate TBSA.

2 arms+1 leg+head/neck=TBSA%

9+9+18+9= 45% TBSA

Children and young adults may survive burns of 20%, whereas the elderly and infants may die from as little as 10 %"( Ambulance Service, 2008). Depending on their age the patient has suffered 20% to 30% TBSA than realistically survivable. The patient has serious burns and condition must be considered critical.

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Burns can cause other complications than those mentioned in (i) and (ii). These include:-

Shock- Occurs from the large amount of fluids lost from damaged skin cells (hypovolaemic/septic shock)

Dehydration and Hypovolaemia- "These may occur in extensive burns due to excessive leakage of water and plasma proteins from the surface of damage skin"( Waugh et el, 2006)

Infection- Severe complication of burns. The barrier of the skin is replaced by Escher. Escher is moist and protein rich. This environment is perfect for microbial growth and can lead septicaemia.

Hypothermia- Due to excessive loss of heat that may occur. The greater the area burnt the more fluid loss.

Renal Failure-"This occurs when the kidney tubules cannot deal with the amount of waste from haemolysed erythrocytes and damaged tissue"( Waugh et el, 2006)

Respiratory Tract Damage- Thorough inhalation of flames or heated smoke.

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"The vast majority of deaths from fires are not from burns, but rather from inhalation of toxic gases, upper airway compromise, or pulmonary injury".( Caroline, 2007). Inhalation of smoke may burn the airways which cause swelling/damage that could reduce the size or close the airway. Oxygen is consumed during the burning of a fire. The patient may find themselves in a low oxiginated area and suffer from hypoxia. "tissue damage and toxic effects caused by the chemicals in the smoke"( Caroline, 2007)may also occur.

The biggest threat of all though comes in the form of carbon monoxide intoxication. Many gases are released during a fire due to the combustion process; carbon monoxide is one of these. "Because CO binds to receptor sites on haemoglobin at least 240 times more easily than oxygen (O2), the patients haemoglobin may become saturated with the wrong chemical. In other words the patient dies of asphyxiation.

The fact that the patients face and neck have been burnt is the initial clue that patient may have upper airway damage/consumed toxic gases. If these areas are burnt it is unlikely the patient has not inhaled super heated smoke.

The patient is struggling for breath and the presence of stridor/wheeze are also an indication. The patient may be struggling to breathe as their upper airway has swollen due to burns and narrowed in size. Stridor is usually present due to an upper airway obstruction.

The patient may also be struggling to breath due to C02 displacing 02 from the alveoli. This coupled with superheated smoke could narrow the upper/mid airways explain the presence of an expiratory wheeze.

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It is commonly believed that patients who suffer from C02 intoxication appear a bright cherry red in colour. This is because when CO is inhaled, it combines with the hemoglobin in red blood cells to produce carboxyhemoglobin, which is bright red ( This may not be the case in this scenario however as "most practitioners agree that this cherry red skin is most likely to be seen in people who have died, not living people".( Caroline, 2007)

It may also seem natural to test the patients 02 saturation using a pulse oximeter (which you may imagine would be low). This is not the case though. "Patients with severe C0 intoxication usually present with an O2 saturation of normal or better"( Caroline, 2007). Instead CO levels should monitored using capnography probe which should show high levels of CO. Capnography probes can also be used as an early indicator of an airway obstruction

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ABCED's. Ensuring open airway. Observe signs of burnt airway (singed nose hairs/burn marks). Early endotracheal incubation before airway closes.

Ensure patient is breathing (quality/rate/depth). Special attention given to presence of stridor or wheeze on auscultation.

Ensure patient has a pulse (quality/rate/depth). Ensure and intravenous (IV) line is established as soon as possible, even though not at the expense of hospital arrival time. Burn areas are not advisable sites to establish an IV line even though not contraindicated.

Expose. Evaluate extent of patients burns and if possible depth. Also observe if any other injuries are present with a quick head to toe inspection.

Disability of the patient. Establish if the patients level of consciousness with a Glasgow Coma Score.

Remove constricting objects/hot clothing not adhering to the skin. This can also include shoes and rings (e.g. fingers may swell). If unable to remove items (especially metallic) should be cooled to prevent further injury. After removing clothing the sudden loss of heat may cause hypothermia so the patient must be kept warm.

Treatment of the burn itself. Initially stop the burning. If safe any fires need to be extinguished. Moisten burn (with water) and cover with sheets/cling film (overlapping) unless a chemical burn. Do not use creams or burst blisters.

Treat for shock. Sodium Chloride fluids (hypovaelemia) and reassurance (emotional "shock").

Administer high levels of humidified O2 or nebuliser saline therapy. Must remember that O2 saturation levels indicated by pulse oximetry may not be accurate.

Advanced pain relief such as morphine is likely to be required.. Entonox is unlikely to be adequate to treat the patient's pain. Establish pain score (1 to 10) if possible. Burns are painful often with multiple injury sites such as damage to the airway and exposed nerve endings of the flesh. Accelerated metabolism rate are also present. This means higher doses of analgesic will need to be given to achieve the required pain relief.

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Part 3

Question 10



Garner JP. Heppell PS.


Chesterfield Royal Hospital, Calow, Chesterfield, Derbyshire S44 5BL, UK.


Cerium nitrate in the management of burns.


Burns. 31(5):539-47, 2005 Aug.


"BACKGROUND: The introduction of early excision of the burn eschar has contributed to a reduction in burn-related mortality but is not appropriate in all circumstances. Cerium nitrate has been used since 1976, usually in combination with silver sulphadiazine, to improve outcome where early excision is not performed. However, has still not gained universal acceptance. The evidence for its use is reviewed. METHODS: A MEDLINE search was performed for the years 1966-2003 using keywords 'cerium', 'sulphadiazine', 'Flammacerium', 'lanthanides' and 'topical therapy for burns'. The reference lists of key articles were then sifted for other relevant articles. RESULTS: Cerium has been shown to reduce mortality and morbidity in the treatment of severe burns. This benefit is derived from its action on the burn eschar. It binds and denatures the lipid protein complex liberated from burnt skin that is responsible for the profound immunosuppression associated with major cutaneous burns. It has only limited antimicrobial properties. CONCLUSIONS: Cerium nitrate is an excellent topical treatment for most cutaneous burns not undergoing immediate excision and closure."

Garner JP. Heppell PS. (2005). Cerium nitrate in the management of burns. Burns. (31(5)): 539-47.


Pham C. Greenwood J. Cleland H. Woodruff P. Maddern G.


ASERNIP-S, Royal Australasian College of Surgeons, and Burns Unit, Royal Adelaide Hospital, South Australia, Australia.


Bioengineered skin substitutes for the management of burns: a systematic review.


Burns. (33(8)):946-57, 2007 Dec.


"OBJECTIVE: To assess the safety and efficacy of bioengineered skin substitutes in comparison with biological skin replacements and/or standard dressing methods in the management of burns, through a systematic review of the literature. METHODS: Literature databases were searched up to April 2006, identifying randomised controlled trials. RESULTS: Twenty randomised controlled trials were included in this review. The numerous sub-group analyses and the diversity of skin substitutes limited the ability to draw any conclusions from it. However, the evidence suggested that bioengineered skin substitutes, namely Biobrane, TransCyte, Dermagraft, Apligraf, autologous cultured skin, and allogeneic cultured skin, were at least as safe as biological skin replacements or topical agents/wound dressings. The safety of Integra could not be determined. For the management of partial thickness burns, the evidence suggested that bioengineered skin substitutes, namely Biobrane, TransCyte, Dermagraft, and allogeneic cultured skin, were at least as efficacious as topical agents/wound dressings or allograft. Apligraf combined with autograft was at least as efficacious as autograft alone. For the management of full thickness burns, the efficacy of autologous cultured skin could not be determined based on the available evidence. The efficacy of Integra could not be determined based on the available evidence. CONCLUSIONS: Additional methodologically rigorous randomised controlled trials with long-term follow-up would strengthen the evidence base for the use of bioengineered skin substitutes."

Pham C. Greenwood J. Cleland H. Woodruff P. Maddern G. (2007). Bioengineered skin substitutes for the management of burns: a systematic review. Burns. (33(8)), 946-57.


Lam NN. Dung NT.


Burn Intensive Care Unit, National Institute of Burns, Hanoi, Vietnam.


First aid and initial management for childhood burns in Vietnam--an appeal for public and continuing medical education.


Burns. 34(1):67-70, 2008 Feb.


"A prospective study to investigate first aid and initial management for 247 paediatric burn patients from 1 June, 2004 to 31 June, 2006 at the Burn Intensive Care Unit, National Institute of Burns (NIB), Hanoi. Data were collected from documents from referring hospitals and direct interview of patients, relative and transport team as guided by the International Society for Burn Injury (ISBI) and the World Health Organization (WHO). Results showed that cooling the burn surface by cold water was applied in 27.17%. Among 132 patients transferred from other hospitals, fluid resuscitation was given in 102 patients (77.28%) before transferring and over a half of these patients were not given intravenous fluid during the time of transfer, especially for children under 1 year of age (p<0.05). Dressings were applied in 36.36% of transferred patients. Burn surface area was accurately diagnosed in only 21.90% of total cases. In conclusion, first aid and initial management in Vietnam are still far from ideal. Further public education and continuing medical education should be applied in Vietnam".

Lam NN. Dunn NT. (2008). Burn Intensive Care Unit, National Institute of Burns, Hanoi, Vietnam. Burns. 34(1):67-70, 2008 Feb.


Schnell. Zaspell.


Department of Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University, Munich, Germany


Cooling extensive burns: Sprayed coolants can improve initial cooling management: A thermography-based study☆


Volume 34, Issue 4, Pages 505-508 (June 2008)


This pilot study was designed to verify whether the spraying of coolant improves initial cooling in extensive burns. The cooling effects of 1l of sprayed water and 5l of poured water (at 22°C) were tested; 53 healthy participants were cooled for 15min over 18% of their total body surface, twice. Thermographic imaging measured the loss of skin temperature and assessed the homogeneity of cooling. With sprayed coolant the mean decrease of skin temperature was significantly higher (p<0.003) throughout the entire cooling period and more homogeneous for the first 9min (p<0.003), compared with poured coolant. Infrared tympanic thermometry estimated core body temperature; neither poured nor sprayed water caused hypothermia. Even with a fifth of the volume of poured water, sprayed water cooled more efficiently. Thus, we conclude that spraying of coolant improves initial management.

Schnell,. Zaspell. (2008). Cooling extensive burns: Sprayed coolants can improve initial cooling management: A thermography-based study. Volume 34, Issue 4, Pages 505-508 (June 2008)


Garner and Heppell=. Critical review and Observational

Pham and Greenwood(etc)=Critical Review

Lam and Dung= Quantitative research

Schnell and Zaspell= Quantitative research and empirical


Both papers highlight key areas of burn management that is currently (or should be) applied by responders, EMTs and paramedics in today's clinical practices. In many ways they are separate papers studying different areas of burn care. However, both papers findings can be compared in many ways and can be considered consistent.

Schnell and Zaspell focus mainly on one area of burn care. Their study reveals the use of spray coolant is more effective on burn patients. This neither is nor currently used in Essex Ambulance (even though this may not apply to other parts of EEAS) and therefore a change in policy/care practise should be considered. The treatment is shown to be more effective in 5 key ways.

By reducing the amount of water coolant the patient is exposed to(through emersion) the chance of hypothermia is reduced

Danger to clinician and others at hand are reduced as there is less spillage of water in the working environment. This includes slip hazards and electrocution (defibrillator).

Over a 15 minute period sprayed coolant is more effective at reducing temperature in desired area with increased harmognity in the 9th, 11th and 14th minute

Simple to use so less trained individuals can use with ease( such as first responders)

Reduces waste and cost as it is only applied to a specific area

Schnell and Zaspell do also mention more general aspects of burn care that are in direct agreement with Lam and Dunn (this will be discussed shortly)

Lam and Dunn is less specific to one aspect of burn care. Instead, it outlines a number of key treatments in burn patients which can be likened to guidelines the East of England Ambulance Service should currently work to.

1. If the transfer of patient to hospital is of reasonable length then fluids should be established before departure. However, if close to hospital delay should not be given to set up fluids.

2. An accurate estimation of burn area is needed. This can be compared to Schnell and Zaspells work. The spray will only work to the precise area it is applied, therefore an accurate estimation is required for adequate treatment.

3. Pain relief should be given to burn patients. As well as being established practise (aggressive pain relief is needed due to increased metabolism) the two papers can also be shown to agree again. Cooling burns with any form of water coolant "is a well-known initial treatment to control pain"( Schnell et el, 2008)

4. Accurate accounts of type/amounts of drugs or fluids given to patient.

5. Pre-hospital care is vital as "appropriate and simple initial treatment, correctly applied, can reduce the depth of injury, pain, as well as complications of burn injury" (Lam et el, 2008).

This statement is backed by a number found in Schnell and Zaspel report. Treatment of the burn must come in the first 30 minutes of injury or treatment could be ineffective. Schnell also claims if this treatment comes in 30 minutes faster and better healing, fewer infections,less scarring, decreased need for skin graft, burn shock prevention, improved circulation and limited tissue damage"


The y axis indicates the temperature (of the patient's skin). The X axis indicates duration (time passed since application). The dotted line represents poured water while the full line represents sprayed coolant.

Bearing this in mind it is clear how the effectiveness of each treatment varies. The dotted line is always above that of the full line. This means as the same amount of time passes the temperature(of the skin) of the poured water(dotted line)is always higher then the temperature(of the skin) treated by sprayed water(full line). Over the same period of time the skin cools at different rates depending on treatment.


Two relevant physiological cooling methods of the body can be likened to the water spray.

Evaporation: - The body when overheated sweats. This moisture on the skin will then evaporate. The process of evaporation uses heat, therefore cooling the skin. Using the spray more water will stick to the intended burn area. Poured water will run of the skin while small droplets from the spray cling to the skin. The more water on the burn area the more effective the cooling process.

Conduction.:- The spray acts like a block of ice being held on the burnt area. The water from the spray is cooler than body temperate. As it clings to the burn area conduction passes heat from that body area to heat the water. The water cools the burn area by drawing the heat out.


S.D means standard deviation. The standard deviation shows how accurate the mean result would be if the experiment were to repeated many more times over. It is how close all results are to the mean (dispersion of results). The smaller the standard deviation the more accurate the mean is. In a way it is a mean of the mean.

This can apply to any statistical study. If a study of the average height of males in the UK were conducted the mean result may be 6 foot. This obviously does not mean all males are 6 foot in the UK. If UK males only varied in height between 6'2" and 5'11" then the mean would be accurate and S.D low. The larger the range of data the less accurate the mean would be and the larger the S.D.

This can apply to Schnell and Zaspells studies. Not all people will react to the treatment the same, people will cool at different rates. The dotted and full line shows the mean temperature decrease of pored water and sprayed water respectably. The S.D lines are represented by triangles.

The S.D line for poured water closely mirrors the mean curve. This means the mean is very accurate. The S.D line for sprayed water still closely mirrors the mean line (even though not as tightly) and is below the mean line. This means the results are slightly less accurate.

Both mean lines are less closely mirrored by their S.D lines over time. This suggests results are more varied between patients the more time that passes from the initial application.


Copyright © 2009 Published by Elsevier Inc.

Airway Management and Smoke Inhalation Injury in the Burn Patient

This article is not included in your organization's subscription. However, you may be able to access this article under your organization's agreement with Elsevier.

Leopoldo C. Cancio MD, FACSa,

aU.S. Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, TX 78234-6315, USA

Available online 28 September 2009.

Smoke inhalation injury, a unique form of acute lung injury, greatly increases the occurrence of postburn morbidity and mortality. In addition to early intubation for upper-airway protection, subsequent critical care of patients who have this injury should be directed at maintaining distal airway patency. High-frequency ventilation, inhaled heparin, and aggressive pulmonary toilet are among the therapies available. Even so, immunosuppression, intubation, and airway damage predispose these patients to pneumonia and other complications.

I have used the above paper(abstract shown) on the initial management of smoke inhalation. When compared to Emergency Care in the Streets both are in agreement with many things.

Both agree the key to treating smoke inhalation is maintaining a patent airway. Early intubation is of high importance as the airway can rapidly swell and close. Again both are in agreement this should be done with an endotracheal tube.

Both agree the need for the patient to receive high levels of O2 therapy. This can even come in the form of high flow oxygen masks or high levels of ventilation with a bag and mask.

Both agree on the use of nebuliser therapy. This however is where the papers begin to differ slightly. Emergency Care suggests a nebuliser with cooled humidified O2. The journal mentions nebulated heparin (an anticoagulant).

Even though both papers agree on the fundamentals of patient care there are areas the two sources do not coincide. For example Emergency Care puts emphasis on patient pain relief even at an early stage. The journal has no mention of this. Emergency Care states the need to maintaining safety to the clinician and the patient where as the journal does not.

Emergency Care also goes into more advanced air way management such as rapid sequence intubation(which only the Heli-med team are able to do). These are only minor points however. Both papers agree without a patent airway patient survival is not possible. The ABC's still apply.


Of all the papers we have had to study the most interesting was Schnell and Zaspell. The paper appealed to me for a number of reasons.

Firstly (presuming their results were accurate) the spray on water coolant genuinely had an improve results to spilled water.

Secondly, from first hand experience I appreciate how the lack of spillage with the spray would help. Not only does it make the surround area slippy it also makes all lifting apparatus slippy. This coupled with a cold day the hands can become numb and the job becomes harder (unnecessary it seems). And that is just me as the clinician, the patients discomfort is greatly increased (unnecessarily).

The final appeal it had to me was how simple and logical the idea is and yet how unavailable it is. As far as I know we as yet do not use the spray. With the benefits offered I wonder why not?