Burns

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    Ok, I thought that I would start putting some stuff in the first aid forum…there hasn’t been a posting here in awhile. I thought that I would post something on burns.

    Burns are an area of concern for me, think about all of the bad things that could happen that could lead to your getting burned. Burn injuries are common and it does not seem like a week goes by without the national news reporting the death of an entire family in a house fire or such. Fire often accompanies disasters such as earthquakes, civil disturbance, hurricanes, and even flooding (electrical shorts, flood waters can spread the burning embers…). In terms of war, burns are fairly frequent, accounting for 6% of all U.S. combat casualties over the past 35 years, since the Vietnam War, and historically burns have accounted for up to 20% of casualties in conventional conflicts.

    A bit about me, so you don’t think that I am just a loon that is parroting something that he read on the net somewhere. I am an RN and I have been working in ERs for the past 11 years. I was a U.S. Navy hospital corpsman, honor graduate of the U.S. Navy/Marine Corps Field Medical Service School, I have been a paramedic, and I am an advance burn life support provider…among other things.

    There are different types of burns: thermal, electrical, chemical. I am only going to talk about thermal, caused by fire and heat, burns here.

    There are 3-4 different degrees of burns:

    First degree (superficial): only involve the outer layer of skin and make it red. The best example is a non-blistering sun burn.

    Second degree (partial thickness): Involves multiple layers of skin, but does not go through the skin. Classically presents with blisters.

    Third degree (full thickness): Involves all layers of the skin and underlying tissues. Classically (but not always) presents with charring. 3rd degree burns don’t hurt…all of the nerve endings that generate pain are destroyed. Now, the edges will hurt, but in the body of the burn you won’t feel a thing.

    Fourth degree (not recognized by all authorities): extends to the muscle and/or bone.

    It is important to know that burns can evolve over time, over the first several hours or even days after an injury, as the body responds to the insult. Ever notice a sun burn at the beach that was blistered by the time you got home? What initially appears to be a second degree burn might actually be a third degree burn by the day after. For example, a hand forced into boiling water for a minute or so. First it is red (1st degree), soon after, it is blistered (2nd degree), and the next day the skin is painless and dead and maybe it doesn’t hurt so much (3rd degree). Don’t worry about the fine points, no need to split hairs…the treatment that you might render is not going to be much affected by such.

    When discussing burns you need to know not only the degree of the burn and the location of the burn, but also extent of the burn in terms of body surface area affected (BSA). For health care workers, BSA is very important in burns, in first aid and general care it is less so. Two quick ways to estimate the BSA is the rule of 9’s and the rule of palm. The rule of 9’s is that various parts of the body occupy 9% of the BSA. One arm is 9%, the head is 9%, the upper chest is 9%, the front of the leg is 9%, and so on. This is only for adults, kids (infants and toddlers) are different. Here is a chart:

    Another quick guide is the rule of palm. A person’s palm covers about 1% of his or her body. To guestimate the size of a burn, look at the victim’s palm and guess about how many palms it would take to cover the burn.

    Again, these are fine points. Unless you are a medical professional being able to correctly describe a person’s burns in terms of degree and BSA is just a nicety and will not greatly affect the treatment that you might render. However, you should know the jist of this stuff.

    Ok, treatment of burns. First, disclaimer: this is for informational purposes only. In the event of an actual emergency, please seek professional medical assistance. Now, moving on.

    Stop the burning. No brainer, but you might be surprised at how often people assume that all is well once the flames are out. Ever suck on an ember?

    Airway, airway, airway. For any burn patient, look first to their airway, the path that air takes to get in and out of their lungs (the nose, the mouth, the trachea, etc). I have seen people come in for burns to their hands that we had to stick breathing tubes into because of airway burns. Think about it: you are close enough to the fire to get burned. Getting burned hurts. When you get hurt, isn’t it natural to take a deep breath (usually in preparation for some screaming/cursing)? What do you think you will be inhaling with that deep breath, since you are close to a fire and hot air does rise? Burns to the airway can cause swelling, swelling so bad that the person’s airway will swell shut and the person will choke to death. This swelling can happen quick, in a matter of minutes, or slowly over a matter of hours. The only treatment for this is usually a breathing tube…so if you suspect an airway burn get help quick.

    Signs of an airway burn include soot in the nose and/or mouth, sooty sputum and phlegm, singed facial and/or nasal hairs, hoarseness, stridor (a high pitched noise made when taking in a breath…sounds a bit like a dog’s squeak toy or a bad whistle), coughing, and shortness of breath.

    Smoke inhalation is another story altogether. The best treatment for that is breathing pure oxygen for hours. Plus, what kind of chemicals did the person inhale? With modern fires, cyanide poisoning is quiet common due to all of the burning plastic. All of this is beyond what I can discuss here.

    No airway involvement? Moving on…

    Keep the patient warm. The skin helps to retain body heat. A burn of more than 10% can predispose someone to hypothermia…talk about extremes.

    Keep the patient well hydrated. The skin helps to retain moisture. The burn is an injury, and anytime you have an injury you will get swelling and swelling is water shifting around in the body. A burn patient can become so dehydrated that his or her kidneys will shut down and fail. Keep the fluids going, preferably through an IV if you can. If you can start an IV, look up the Parkland formula. Whether you are giving the fluids by mouth or by IV, make sure that the patient continues to pee. The average adult should produce at least an ounce of urine every hour…less than that and the kidneys might be in trouble.

    Keep the burn clean and sterilely dressed. Initially cleaning a burn is not that important, not like for a cut or such. The fire that is causing the burn probably burned out all of the bacteria. Just try and get any chunks of dirt, burned clothing, and such out. However, the skin is our primary barrier to infection, and a burn can deprive someone of a lot of skin…leaving a burn victim open to infection. Keep the wounds clean and use the most sterile dressings that you can get.

    How to dress a wound? Wet or dry dressings?

    For first or second degree burns involving 10% or less BSA, you may use wet dressings (like Burn-Jel/Water-Jel). For larger burns or 3rd degree burns, use dry dressings. All that the wet dressings do is east the pain some. The risk of causing hypothermia is too great to justify the use of wet dressings in wounds larger than 10% BSA. Wet dressings can increase the risks of infection…the water can wick bacteria to the burn. Also, with a third degree burn there will, usually, be little pain since only the edges will hurt…so there is little use for a wet dressing with 3rd burns. See what I mean by you just need to know the jist of BSA calculation and degree of burn determination?

    If you don’t have Burn-Jel/Water-jel, you can improvise a wet dressing by applying a dry dressing and then saturating it with sterile saline. In my posting on DIY medical items I gave a recipe for making saline…just make sure that if you make your own you add a water purification tablet to it and wait the appropriate time for it to work.

    For dry dressings you can use just about any sterile medical dressing material. You might consider stocking up on some burn sheets…these can cover the entire body and can be cut to size…but do your best to keep them sterile…don’t touch the wound or the part of the dressing that will be touching the wound. I have worked in cash strapped EMS systems before where we used sterilized, low thread count (less threads, less lint) bed sheets for burn sheets. Perhaps you could sterilize the sheets in a pressure cooker and set them out to dry in an area you have cleaned with bleach, in a pinch.

    You can also consider using a burn cream. Perhaps the best, and most commonly used, is Silvadene (silver sulfadiazine). You can get a small jar of it for $10 from Amazon (http://www.amazon.com/Thermazene-Silver-Sulfadiazine-Cream-grams/dp/B0008KLQNM/ref=pd_sim_hpc_1″ onclick=”window.open(this.href);return false). The way that I apply it is with a sterile popsicle stick, smearing it on thick, and then covering it with a dry, sterile dressing. The Silvadene protects the burn from infection and cuts down on the dressing sticking to the burn. Silvadene is sliver based, so it can stain the skin (I have never seen this happen) so it should not be used for the face…Neosporin works good there.

    A cheap alternative to Silvadene is honey. I have read of studies comparing honey to Silvadene, and the honey was found to be as, If not more, effective in preventing infection. Supposedly some forms of honey are better for this than others…one from New Zealand is supposed to be the best. But if you can’t buy the Silvadene from Amazon, what are the chances that you will be able to import honey from New Zealand?

    Dressings should be changed at least once, if not twice, a day. I am not going to go into debridement (removing the dead skin)…but if you pull something off with the dressing, then so be it.

    Most of the complications of a burn are what I have already touched upon: infection, dehydration, and hypothermia. Pain is a big problem, be generous with any pain relievers you might have.

    Another complication of burns is compartment syndrome. This is where there is extensive swelling in an area like an arm or a leg, swelling so severe that it cuts off the flow of blood. This is most common in circumferential burns…burns that go all the way around an arm or a leg. If you are caring for such a burn, make sure that you feel for a pulse past the burn (in the wrist, or on top of the foot) frequently (about once every hour or two for several days). A circumferential burn of the torso can make it impossible for a person to breath. The treatment for these complications is an escharotomy (feel free to Google it).

    Again, I urge you to seek any professional medical assistance available should you have a medical emergency. Most definitely you should seek assistance for: extensive burns (even a sunburn that covers 50-60% BSA); any third degree burn; any second degree burn covering more than 2-3% BSA; any circumferential burn; any burn to the face, hands, feet, or genitals; and for any complications that you notice.

    Prevention of burns is much more effective than treating burns, and less painful. Whenever possible, build with stuff that will not burn. Try and have no open flames (including cigarettes, smoking is bad for you anyway) and if you must use candles and such treat them with the same respect you would show a loaded gun. Keep smoke/heat detectors throughout your home, and I would urge you to get a carbon monoxide detector too. Test these regularly. Keep fire extinguishers, and check them regularly. They really don’t costs that much, you might want to buy an extra one for your family to practice with. Ensure that you have fire exits throughout your house (ever hear of someone trapped in a burning house by burger bars? What about those rope ladders for second floor windows?) Keep enough water hose available to spray down your house, should there be a fire near-by. In the event of a grid-down situation, keep buckets of dirt and sand available throughout your house to douse a fire with (or just sand bags around the windows? Ballistic and fire protection, two for one). Consider purchasing an Indian pump, or even a back pack garden sprayer. In a rural area, consider how you might make a fire break, such as with a controlled burn, to stop a wild fire from overwhelming you. Don’t forget, a shove, an axe, a chain saw, a lawn mover…all of these can be fire fighting tools. If you have a gas mask, use it with caution to avoid smoke inhalation. I say with caution because it ill not protect you from hypoxia. Fires literally burn up the oxygen, and a gas mask won’t supply that. Lastly, don’t forget about clothing. Some clothes will ignite if you look at them wrong, others won’t burn if you beg them too. Nomex, of course, is good…but so are surplus BDUs.

    For further reading, might I suggest the Field Medical Service Manual: http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Manuals/FMSS/BURNCASUALTIESFMST0402.htm” onclick=”window.open(this.href);return false
    and chapter 28 of Emergency War Surgery: http://www.bordeninstitute.army.mil/other_pub/ews.html” onclick=”window.open(this.href);return false

    Sorry for rambling so, but I hope you find this helpful.

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