Burns are one of the nastiest types of injuries to deal with. They can vary from very minor which heal without any treatment to critically severe that without advanced interventions will result in the long and suffering death of the burned patient. This article is for information only!! It is not intended to replace the use of doctors and hospitals. In order to discuss burns, we must first understand a little about the integumentary system, more commonly called, the skin!
The skin is made up of three layers: the epidermis-the outermost layer, the dermis-the middle layer, and the subcutaneous layer-the deepest layer (also called the fat layer). These different layers range in thickness from one-cell layers to several cell layers and provides the body with a barrier from infection. It also insulates the body from the outside elements, aids in temperature control, provides us with a means to transmit sensations like hot, cold, sharp, soft, etc. It is the largest organ of the body and when it is damaged by a burn, any or all of these functions can be impaired or destroyed.
Burns are assessed by their depth, and there are three classifications of that depth. A first degree burn, also called a superficial burn, is one that only involves the outermost layer of skin, the epidermis. It can be caused by a flame, scald, or the sun. The most common first degree burn is the common sunburn. The skin of a first degree burn will be dry and pink to red, and occasionally some swelling, but there will NOT be any blisters. This type of burn is very painful because the nerve endings have not been damaged and the person burned can feel it completely. It can take several days to a week for this type of burn to heal. There is nothing that can be done to expedite the healing, but there are means to lessen the pain. A soothing, cooling lotion such as aloe vera may help, as well as commercial sunburn remedies like SolarCaine. They provide temporary relief of the symptoms, but unless they include a moisturizer, may dry out the skin even more leading to “peeling”. This sloughing of skin is the dead skin cells that were damaged by the burn coming off of the skin as new skin cells are produced. As these new skin cells grow, the burned person may experience intense itching.
A second degree burn, or partial thickness burn, involves the epidermis and the dermis. They are caused by flame, or a flash, hot liquids, hot solid objects, chemicals, or the sun. The skin will appear cherry red, moist and mottled (uneven colored), and will have the defining characteristic of second degree burns, blisters. These blisters are a result of damage to the blood vessels which cause the plasma and interstitial fluid to rise to the surface of the skin, forming bubbles under the epidermis. This type of burn is extremely painful because the nerve endings have been damaged but not destroyed, and unless it covers more than 30% of the body, will heal on its own in 2 to 4 weeks.
A third degree, or full thickness burn, is when the epidermis, dermis and subcutaneous layer are burned. Sometimes the burn will extend into the muscle, bone, or organs below the burned area. Third degree burns are the result of contact with an extreme heat source such as electricity, prolonged exposure to flame, boiling liquids and chemicals. Most full thickness burns are not very painful because the nerve endings have been destroyed. What is painful is the area around the third degree burns, which is usually a combination of first and second degree burns. Third degree burns usually require advanced interventions, including surgery, especially if they cover more than 10% of the body surface. Healing time depends on the size of the burn and can be anywhere from a few months to a few years! There is usually extensive scarring after a third degree burn heals completely.
One other type of burn is the inhalation burn. Mostly seen in firefighters, this is when the patient has inhaled superheated air. One sign that is a good indicator that the patient may have a supraglottic (above the glottis) heat injury, is swollen lips. If a patient has swollen lips, be prepared to perform advanced airway interventions. Also, be prepared for the patient to experience severe shortness of breath and treat it accordingly with high flow oxygen. Maintain a close watch on the vital signs and the breath sounds for this patient could very quickly lapse into pulmonary edema.
Not only do we have to determine the classification of the burn, but also the amount of the body that was burned. We do this by calculating the percentage of the body surface area (BSA) that was burned. There is a method called the “Rule of Nines” used to determine what percentage is burned. With this method, each part of the body is given a percentage of how much BSA it covers and the total of all body parts is 100%. The percentage designations in the Rule of Nines changes between adults, children, and infants. Here are the percentage designation.
Infant (NewBorn –1yr)
Head-9 Head-18 Head-18
Front, Upper Torso-9 Total Front Torso-18 Front Torso-18
Front, Lower Torso-9 Total Rear Torso-18 Rear Torso-18
Front Right Leg-9 Front Right Leg-7 Right Arm-9
Front Left Leg-9 Front Left Leg-7 Left Arm-9
Front Right Arm-4 ½ Rear Right Leg-7 Right Leg-14
Front Left Arm-4 ½ Rear Left Leg-7 Left Leg-14
Rear, Upper Torso-9 Front Right Arm-4 ½ Genetalia-1
Rear, Lower Torso-9 Front Left Arm-4 1/2
Rear Right Leg-9 Rear Right Arm-4 1/2
Rear Left Leg-9 Rear Left Arm 4 1/2
Rear Right Arm-4 ½ Genetalia-1
Rear Left Arm-4 ½
Notice the differences in the proportions between adult and child. The reason for this is a child’s head is much larger proportionately than the rest of its body so it gets counted as 18%, as does the front and back of their bodies. Children also face other risks when burned including the potential for greater fluid loss and increased scarring which can impede the growth process.
The location of burns is also of importance. Burns to the face are considered severe due to increased possibility of respiratory compromise. Burns to the hands and feet are critical because it could mean a loss of function for the patient. Genitalia burns are severe because they will compromise urinary and /or bowel function and can lead to increased infection from unchanneled excrement. Also of concern are circumferential burns where the burn encircles an entire body part. Circumferential burns to extremities can lead to circulatory compromise in that extremity, and to the chest can be critical due to loss of expansion and contraction during respiration.
Burns fall into three categories, minor, moderate,
Minor: 3rd degree burns involving less than 2% BSA
2nd degree burns involving less than 15% BSA
Moderate: 3rd degree burns covering
2% to 10% BSA, EXCLUDING face, hands, feet, genitalia, or respiratory tract.
2nd degree burns of 15% to 30% BSA
1st degree burns of greater than 50% BSA
Any burn involving the respiratory tract or involving other major traumatic injury (i.e. broken bones, large lacerations, etc.)
2nd or 3rd degree burns involving the face, hands, feet, genitalia, or respiratory tract
Any 3rd degree burn covering more than 10% BSA
Any 2nd degree burn covering more than 30% BSA
Any 2nd or 3rd degree circumferential burn to any extremity
Any moderately classed burn in children less than 5 years or older than 55 years of age
There are five agents of burn sources. The
first is a thermal burn, which includes flame, radiation of heat
from excessive heat source, steam, hot liquids, and hot solids. The
second is chemical burns, including, various acids, bases, and caustics.
Often cooling with water is insufficient for chemical burns; a neutralizing
agent must be used. Third is electricity, AC current, DC current,
and lightening. These types of burns are often accompanied by
life-threatening cardiac arrythmias and possibly broken bones. The
forth is inhalation burns caused from breathing super heated air.
The last is radiation burns, which can come from common sunlight
to nuclear radiation. Burns from light can be as simple as sunburn
to complicated retinal burns from ultraviolet exposure to the eyes.
Those of you who carry a Tritium compass should be aware that the tritium
pellet inside it is radioactive and if you left the compass against your
skin for several days, a blister will develop. This blister is in
fact a small second degree burn.
Treatment of Burn Injuries
The three major goals in treating burns are a) stop the burning process, b) preventing further injury and contamination, and c) preventing hypothermia. In most situations, water can be used to stop the burning process and to cool the burn, preventing further injury. The only case where water would be contraindicated would be for certain chemical burns. Powdered Lye, for example, is one substance when mixed with water begins to burn. The best way to be able to handle an emergency when dealing with chemicals is to know about the substances you’re dealing with and the proper emergency guidelines to follow incase of an exposure. Remember, with chemicals, the agent does not have to be “on fire” to burn the skin. To prevent contamination, the patient should be wrapped in a sterile burn sheet after the clothing has been removed. Lastly, the skin is a major factor in the body’s temperature regulation, and when it is damaged, that control goes haywire. The body thinks it is too hot and will begin to cool itself off, and in doing so can push the patient into hypothermia. After wrapping the patient in a sterile burn sheet, regular blankets should be place over and under the patient to aid in retaining warmth. If possible, keep the ambient temperature in the room where the patient is kept warm, even during summer months.
Initial care will include looking over the scene where the patient is. Is it safe to remove him from danger? Is the fire out? Are there live electrical wires down? If it is a chemical exposure, what is the wind direction and what substance (s) are you dealing with? Remember, the rescuer's safety is first and foremost. Going into a dangerous situation and getting hurt yourself only compounds the problem. After determining the area and patient are safe to approach, find a means to extinguish any active burning on the patient, by means of water, smothering, etc. IF the burn is simply by fire, water is the best means to extinguish burning, because at the same time you are cooling the burns. Next remove all clothing, jewelry, and other things the patient may be wearing. If clothing is melted to the skin, make sure it is completely saturated with water and not smoldering, and leave it in place to be removed during debridement (pronounced de-breed-ment). Once you have extinguished all active burning and removed the clothing, wrap the patient’s entire body in a sterile burn sheet, and then begin your primary survey of the ABC’s, Airway, Breathing, and Circulation. You can establish this fairly quickly by asking the patient what happened. If he/she answers you, you have determined with this one question that the patient has a patent airway, is breathing, and blood is circulating. If they do not answer, determine why. Are they unconscious? Is the airway occluded, possibly from edema from burns to the face? Follow the ABC’s. Open the airway, then check to see if the patient is breathing. If they are, assess the pulse at the carotid pulse point. Is there a pulse present? If so, go to the secondary survey. If you answered no to any of these questions, follow the CPR guidelines. In a PSHTF scenario, establishing CPR will most likely be a terminal event.
The secondary survey is where we will determine the extent of the injuries to the patient. Cut away any clothing remaining on the patient. Next take every precaution necessary to keep the patient clean! Infection is rampant with burn victims. Wear gloves and a mask. Now starting at the patient’s head, begin to examine the entire body in a “head to toe” process, leaving nothing out. With burns pay close attention to the hair. Is it singed or melted? Look closely at the face. Are the eyebrows and eyelashes intact or singed off? Is there soot around the nose and mouth? Look in the nostrils, are the nasal hairs singed? Is the patient coughing? If so, are they producing any phlegm? Is the phlegm black or brown colored with ash? Are the lips blistered or swollen? Are the ears blistered? Any obvious burns on the head or face? Next look at the neck. Does it appear swollen? Are there any obvious burns on it? Now the front torso. If it is a man, is the chest hair singed or burned off? Are there obvious burns on the chest or abdomen? If you know how to listen for lung sounds, when listening over all lobes does is sound clear? Is there wheezing, rhonchi, or rales? Now look at the arms, is the hair singed or burned off? Are there obvious burns on the skin? Don’t forget to look under the arms. Are the hands burned? Check the radial pulse. Now the pelvic region. Is the genitalia intact? Pubic hair singed? Move to the legs. Is the leg hair singed or are there any obvious burns? Include the feet, tops and soles. Check the pedal pulse. Now with help, roll the patient onto his/her side and check the back, buttocks, and the backs of the legs. Any burns, singed hair noted?
Now you have completed your secondary survey and should be able to estimate the severity of the burns, the BSA involved, and give a full report to the medic. It would sound something like; “The patient was burned from falling into a camp fire. His shirt caught on fire and friends got him out of the fire and rolled him on the ground with a blanket to smother the flames. He was then cooled with copious amounts of water. The burned clothing was cut away. He is conscious, alert, and oriented to time, place and event and has second degree burns to his hands, arms, chest, abdomen and face, totaling 36% BSA. There were no circumferential burns. The hair on the front of his head and his facial hair is burned off or melted in some areas, nasal hairs singed. Pupils are PERRL, though his eyelashes are singed. He complains of blurry vision and stinging/burning in the eyes; eyelids are intact. The unburned skin is warm and diaphoretic (sweaty), his mucosa is pink and cap refill is less than one second. He has some shortness of breath, but his lung sounds are clear and equal bilaterally. His abdomen is soft, and tender to surface palpation, but not deep palpation. He has good sensation, cap refill and distal pulses in all extremities. He does have some limited range of motion secondary to pain.” Now the medic knows what he/she is dealing with and can treat it.
Treatment of Burns
As stated before, the majority of burns will heal on their own. The ones that are classed as severe will need advanced intervention. Again with treatment it goes by the ABC’s. If Oxygen is available, provide it at the appropriate rate. Be watchful of the airway and breathing status, for it can change quickly. Just because the breath sounds are clear and equal initially, doesn’t mean they will remain that way. Burn patients lose body fluid quickly and can become fatally dehydrated quickly. The plasma that circulates in the blood begins to move into the interstitial tissues and the body begins to swell. The patient must be rehydrated with IV fluids. Two large bore IV’s (18 gauge or larger) with one liter bags of Lactated Ringers should be started in UNBURNED tissue. LR is the fluid of choice, but if it isn’t available, Normal Saline can be used. This can be tricky if a large amount of BSA was burned. Find the veins where you can…legs, feet, groin, neck…wherever, but get the lines in place. There are two common methods for determining how much fluid to infuse into a burn patient. The first is the Parkland formula, the second is the Modified Brooke Formula. With both of these formulas you will need to know the % BSA burned and the patient’s weight in kilograms (there are 2.2 lbs. per kilogram). For the Parkland formula, take the % BSA burned, multiply it by the patient’s weight in kilograms them multiply that by 4cc. The answer will be the total amount of fluid in cubic centimeters (cc’s) to be infused in the first 24 hours. Take the answer and divide it by two and that is the amount of fluid to be infused in the first eight hours. The remaining fluid should be infused over the last 16 hours.
The Modified Brooke formula is basically the same, except, after multiplying the %BSA burned by the patient’s weight in kg’s, multiply the answer by 2cc. The procedure is the same as far as dividing it in half and infusing the first half in the first eight hours and the last half in the remaining 16 hours.
There is a big difference in the amount of total fluid infused between these two formulas. To determine which to use, you must look at the determining factor of how much fluid the patient needs. That factor is urinary output. Acceptable urinary output for an adult is ½ cc/kilogram/hour. For children under 30 kg (66 lbs.), acceptable urinary output is 1cc/kg/hr. Regulating the IV fluids to obtain adequate U/O is the basis for fluid resuscitation. Remember though, more isn’t always better. We also don’t want to cause fluid overload, indicated by voluminous U/O’s. While monitoring the input of fluids and output of urine, vital signs must be monitored. The pulse rate should remain at or below 115 beats per minute but not below 60, and the patient should remain alert and oriented. If they sleep, they should be easy to rouse and know where they are and what happened.
Most moderate and severe burns will require pain management. This can be achieved through a multitude of medications. Just be sure the patient doesn’t have an allergy to the drug given and know that with some pain killer, specifically, narcotics, there will be some change in mentation. Pain management will be especially necessary before debridement. Debridement is a surgical process where the dead, burned skin is “washed” or “scrubbed” away. It is very painful and leaves the patient with raw, red, unprotected skin. Debridement should be done under sterile conditions, and should be done after the patient’s vital signs have stabilized. Another surgical intervention sometimes used with burns is called Escharotomy. This is usually performed on areas of circumferential burns where the swelling exceeds the arteriolar pressure. The results are decreased or absent blood flow to the rest of the extremity. To relieve this swelling and the pressure it’s creating, vertical cuts are made in the skin to release the fluid build up. This is a particularly nasty procedure and it should only be done by experienced medics. Antibiotic therapy is a must with burn patients as well as vigilance with changing dressings and keeping the burns clean.
Other special situations: Electrical burns- whether
the source was AC/DC current or lightening, electrical injuries are very
serious, mainly because there is usually more trauma involved than just
burned skin. When contact is made with an electrical source, the
body, unless grounded, will conduct the electricity through it. The
results are devastating. Much like a gunshot wound, electricity will
have an entrance and an exit wound. Both can be anywhere. The
current will not necessarily follow a straight path through. This
current going through the body can cause broken bones, seared muscle tissue,
destroy organs, and even full cardiac arrest. The heart works off
of electricity too, and if it’s own current is interrupted, it will go
into “fibrillation”, which is like quivering. Using a defibrillator
can reverse it, but with burns, it is very unlikely.
Ocular burns-burns to the eyes are usually associated with light or chemicals. First determine if the patient is wearing contact lenses and if so remove them. Flush the eyes with copious amounts of sterile water or neutralizing solution (for chemicals). Then cover both eyes with dry sterile dressings. With eye injuries, always cover both eyes. The eyes move synchronically, together. If the good eye moves, the injured eye will move with it, hence impeding healing. If antibiotic eyedrops are available, they should be applied as recommended. Use of oral antibiotics will not help ocular injuries or infections because the eyes do not receive their oxygen supply from the blood. They get it from the ambient air, so antibiotics that are taken orally and distributed through the blood stream will not be effective for eye injuries.
Most of the time burns are caused from carelessness. Be mindful of what you are doing, especially if it involves fire, chemicals, or electricity. As you can see, burns will be a hard thing to treat in a PSHTF scenario.
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