Treat a Casualty with a Burn Injury

 

INTRODUCTION

 Burns are among the most serious and painful of all injuries.  The sources of this energy are heat, toxic chemicals, electricity, and ultraviolet and nuclear radiation.  Caring for a burn patient may present other problems: the scene may be hazardous, the fire or substance that caused the burn may have to be extinguished or removed, the patient may be experiencing shock or respiratory arrest caused by the burn, and may have sustained fractures from falling.  You must also be aware of and avoid energized wires, toxic fumes and smoke or the exposure to radioactivity that may have caused the burn.

 

Anatomy and physiology of the skin

The skin is made up of three layers and is the largest organ of the body

(1)        Epidermis

(a)        The surface or outer layer

(b)        Serves as a barrier between our body and the environment

(2)        Dermis

(a)        Thick layer of collagen connective tissue below the thin epidermis

(b)        Contains the important support structures and sensory nerves, i.e., hair follicles, sweat glands, oil glands

(3)        Subcutaneous

(a)        Layers of fat tissue and soft tissue beneath the dermis

(b)        Serves as a barrier for shock absorption and insulation

(4)        Functions of the skin

(a)        A protective barrier sealing fluids inside and preventing bacteria and other microorganisms from entering the body

(b)        Important sensory organ providing input to the brain on general and specific environmental data; serving as a primary role in temperature regulation

(5)        When heat or caustic chemicals come in contact with the skin, damaging its chemical and cellular components, you have burn-damaged tissue and inflammatory responses to the skin

 

Recognize the mechanism of injury and eliminate the source of a burn

The source of the burn must be eliminated before any evalua­tion or treatment of the casualty can occur

 

Thermal burns

(1)        If the casualty's clothing is on fire, cover the casualty with a field jacket or any large piece of nonsynthetic material and roll him or her on the ground to put out the flames.  All clothing should be removed.

Chemical burns

(1)        Remove liquid chemicals from the burned casualty by flushing with as much water or other nonflammable fluid as possible

(2)        Remove dry chemicals by carefully brushing them off with a clean, dry cloth.  If large amounts of water are available, flush the area.  Otherwise, apply no water. Small amounts of water applied to a dry chemical burn may cause a chemical reaction, transforming the dry chemical into an active burning substance.

(3)        Smother burning white phosphorus with water, a wet cloth, or wet mud; keep the area covered with the wet material to exclude air and to prevent the particles from burning

Electrical burns 

(1)        If the casualty is in contact with an electrical source, turn the electricity off if the switch is nearby.  If the electricity cannot be turned off, drag the casualty away from the source using any nonconductive material (rope, clothing, or dry wood).  Do not touch the casualty or the electrical source with bare hands.

(a)        Electrical Currents

(i)         Alternating Current (AC) - is a range that includes house current in most locales and tends to cause ventricular fibrillation if the pathway includes the heart

(ii)        Direct Current (DC) - is much less dangerous than AC; however, electrochemical skin burns have been reported from DC current

Inhalation injuries

(1)        Classified as carbon monoxide poisoning, heat or smoke inhalation injuries

(2)        These injuries account for more than half of the 12,000 burn-related deaths per year

Laser burns

(1)        Move the casualty away from the source while avoiding eye con­tact with the beam source.  Be careful not to view or walk into the beam or you may become a casualty. 

(2)        Never look at the beam source, and if possible, wear appropriate eye protection. Sources of laser beams include range finders, weapons guidance systems, communication systems, and weapons simulations.

 

Assess the severity of the burn

Initial evaluation of a burn patient

(1)        Depth of burn

(2)        Extent of burn

(3)        Age of the patient

(4)        Pulmonary injury

(5)        Associated trauma

(6)        Special considerations- electrical, chemical

(7)        Preexisting illnesses

 

Depth of burn

(1)        First degree - minor tissue damage to the outer epidermal layer only, causing an intense and painful inflammatory response

(a)        Various medications used to help speed healing and reduce the painful inflammatory response

(b)        Also described as a superficial burn because there are layers of skin cells left that can multiply with resultant healing

(i)         Cause -minor flash or sun

(ii)        Skin color -red

(iii)       Skin surface -no blisters and dry

(iv)       Sensation -painful

(v)        Healing -3 to 6 days

 

(2)        Second degree -may cause damage through the epidermis and into a variable depth of the dermis

(a)        Burns will normally heal without scaring

(b)        Treatment includes antibiotic creams or various specialized types of dressings

(c)        Provide appropriate medical evaluation and care for these patients

(d)        Also described as a partial thickness burns because there are layers of skin cells left that can multiply with resultant healing

(i)         Cause -flashes, flame, or hot liquids

(ii)        Skin color - mottled red

(iii)       Skin surface -blisters with weeping

(iv)                   Sensation painful

(v)        Significant fluid loss and subsequent shock may      occur

(vi)       Healing -depending on depth, 2 to 4 weeks

(3)        Third degree - damage to all layers of the epidermis and dermis

(a)        There are no layers of skin cells left

(b)        Healing is impossible except in small third-degree burns that usually scar in from the sides

(c)        All third-degree burns leave scars

(d)        Deeper third-degree burns usually result in skin protein becoming denatured and hard, leaving a firm leatherlike covering that is referred to as eschar

(e)        All layers of skin are destroyed, no skin cells remaining to allowing healing

(f)         Referred to as full thickness burn

(i)         Cause -electricity, chemicals, hot metals and flame

(ii)        Skin color - charred translucent and/or pearly white; parchment like

(iii)       Skin surface - dry with thrombosed blood vessels

(iv)       Sensation - anesthetic

(v)        Healing - skin grafting required

(4)        The severity of burn injuries depends on the depth and extent of the burn -management and initial care must concentrate on limiting progression of these two factors

 

Determine the extent of the burn

(1)        Apply the rule of nines to the burn casualty to determine the percentage of body area burn in an adult

(a)        Head and neck equals 9 percent

(b)        Anterior trunk equals 18 percent

(c)        Posterior trunk equals 18 percent

(d)        Anterior upper extremities equal 9 percent

(e)        Posterior upper extremities equals 9 percent

(f)         Anterior lower extremities equal 18 percent

(g)        Posterior lower extremities equal 18 percent

(h)        Perineum (groin) equals 1 percent

 

Estimating scattered burns:

The patient's palm surface of the hand represents approximately one percent of his/her total body surface area (BSA).

Using the palmar surface as a guideline, even the extent of irregularly disposed burns can be estimated.

 

(2)        Apply the rule of nines to the burn casualty to determine the percentage of body area burn in an infant/child

(a)        Head and neck equals 18 percent

(b)        Anterior trunk equals 18 percent

(c)        Posterior trunk equals 18 percent

(d)        Anterior upper extremities equal 9 percent

(e)        Posterior upper extremities equals 9 percent

(f)         Anterior lower extremities equal 14 percent

(g)        Posterior lower extremities equal 14 percent

(h)        Perineum (groin) equals 1 percent

 

The heads of infants and young children are larger in relationship to the rest of the body than adults and require a modification to the rules of nine in estimating the extent of burns.

 

Age of the patient

(1)        Age has a significant impact on survival

(2)        The very young and the very old respond poorly to burn injury

 

Pulmonary Injury

(1)        Smoke inhalation accounts for over ˝ of the burn deaths annually

(2)        Most inhalation injuries are caused by smoke particles, carbon monoxide and toxic fume inhalation.  These injuries are not immediate apparent.

(3)        ALWAYS assume an inhalation injury in an enclosed space fire

 

Associated trauma

(1)        Explosions and lightening may throw patients some distance from the original injury.  Assess for related traumatic injury

 

Special considerations

(1)        Electrical burns are usually more serious than they appear on the skin surface

 

Preexisting illnesses

(1)        Chronic cardiac, pulmonary, renal or liver diseases have a negative impact on a patient’s prognosis

 

Manage the casualty with thermal burns

First priority: remove the burn source

 

Dangers in removing the burn source:

(1)        "Flash-over" - a sudden explosion into flames -temperature rising instantaneously to over 3,000 degrees.  Removal of victims from burning buildings takes priority over all other objects in the environment- there is no warning for a flashover.

(2)        Rescuers become victims of chemical burns because of the inability to note sources of caustic and toxic chemicals. All rescuers should be trained in hazardous materials management.

(3)        Electrical wire is hazardous and dangerous. Unless you are trained to do so, DO NOT attempt to remove wires. Objects commonly felt to be safe, i.e., wooden sticks, manila rope, firefighters gloves, may not be protective and may result in electrocution. If at all possible, turn off the source of electricity before any rescue attempt is made.

 

Management of burns

(1)        Primary Survey

(a)        A, B, C, D, E 

(b)        Initiate IV hydration with large bore needle and Ringer’s Lactate solution or Normal Saline

(c)        Fully expose the patient removing all clothing, watches and jewelry as combat situation dictates

(d)        Oxygen initiation, if available

(e)        Cardiac monitoring, if available

(2)        Record the mechanism of injury, depth of burn, extent of burn, age of the patient, any associated pulmonary injury, preexisting illnesses and chemical/electrical details.

(3)        Secondary survey

(a)        Continue evaluation of the burn

(b)        Estimate of the depth based on appearance

(c)        Rough calculation of the burn size by using the rule of nines

(i)         The body is divided into areas that are assigned either 9% or 18% of total body sizes

(ii)        By roughly drawing in the burned areas, the size can be estimated

(iii)       Estimate the size, for smaller or irregular burns,       using the surface of the victim's hand as about 1% of the total body surface area

(d)        Calculation of IV rehydration rates for burn patients

(i)         The burn patient needs 2 to 4 ml. of Ringer’s Lactate solution/Normal Saline per kg of body weight per percent of body surface burn in the first 24 hours to maintain blood volume and urinary output.

(ii)        One-half of the total estimated fluid is infused in the first eight hours, the remainder of the fluid is infused over the next sixteen hours.  Calculate as post burn requirements not after arrival at the BAS.

(iii)       Calculate fluid requirements based on the time from injury, not from the time fluid resuscitation started

(iv)       Example:  70 kg patient with 50% second degree burn

4 ml X 70 kg X 50% = 14,000 ml of IV fluid/24 hr.

7,000 ml of IV fluid/8 hr.

(v)        As with all burn formulas, this is an estimate of fluid resuscitation

(4)       Wound Care

(a)       Wrap patient’s burns in a dry sterile dressing.

(b)       DO NOT apply ointments or solutions

(c)       DO NOT open blisters

(d)       If hands or toes are burned, separate digits with sterile gauze pads.  Moisten the pads with sterile water.  Apply loosely. The hand should be in a position of function.

(e)       Burns to the eyes - Do not open eyelids if they are burned. Be certain burn is thermal and not chemical.  Apply moist sterile gauze pads to both eyes. 

(5)       Considerations

(a)       Medications are rarely needed for the burn itself. Use extreme caution when administering pain medications – the status of associated injuries is unclear, and thus medication administration can be dangerous.  When administering Morphine Sulfate, be aware of the indications and contraindications of this drug as they relate to burns.

(b)       Tetanus - when in doubt administer

 

Manage the casualty with chemical burns

Countless types of chemicals can cause burn injuries

(1)        Most chemical burns are caused by industrial sources of chemicals

(2)        Most are caused by strong acids, bases (alkali), or organic compounds

(3)        The fumes can cause inhalation burns

(4)        The eyes may be involved

 

Signs and symptoms

(1)        Reddening, blistering skin

(2)        Pain (mild to intense)

(3)        Obvious deterioration of skin

(4)        Chemical odor

 

Chemicals not only injure the skin, but also may cause internal organ failure due to absorption

(1)        Lung tissue damage through inhalation and subsequent life-threatening respiratory failure

(a)        Frequently deceiving -initial skin changes may be minimal and burns may not be obvious

(b)        Take precautions not to get these chemicals on yourself

(c)        The pathologic process causing the tissue damage continues until the chemical is either consumed in the damage process or until it is removed

(2)        Inactivation using neutralizing chemicals is dangerous because these neutralizing chemicals generate other chemical reactions that may worsen the injury

 

To remove the chemical:

(1)        Wear protective gloves, eyewear, etc.

(2)        Remove all clothing covered with chemicals

(3)        Irrigate copiously, with any source of available water or other irrigant, to flush chemicals off the body

(4)        Wipe or scrape any retained agent that sticks to the skin

(5)        Continue flushing 15 minutes (unless a critical or unstable situation warrants transport sooner)

(6)        Irreversible damage will occur in the eye quickly because of caustic chemicals -irrigate to prevent severe and permanent damage to the corneas

(7)        During irrigation, remove contact lenses. Although soldiers will not generally be wearing contact lens, be aware of this precaution when treating aircrew members.

(8)        Brush off dry chemicals on the skin before performing irrigation

(9)        Chemical burns to the eyes

(a)        Immediately flood the eyes with water

(b)        Hold eyelids open; wash medial (nasal) to lateral

(c)        Wash for at least 20 minutes; transport while washing

(d)        Cover both eyes with moistened pads

(e)        DO NOT use neutralizers such as vinegar or baking soda

(10)      PROTECT YOURSELF DURING THE WASHING PROCESS.

 

Manage the casualty with electrical burns

Electricity entering the body and traveling through the tissues causes tissue damage.

 

Because of their small size, extremities usually have more significant tissue damage.

 

This damage is due the higher local current density

(1)        Severity of electrical injury is determined by:

(a)        The type and amount of current, path of the current, and duration of contact with the current

(b)        Immediate cardiac dysrhythmias are the most serious injury that occurs due to electrical contact. A careful, immediate evaluation of a patient's cardiac status and continuous monitoring of cardiac activity is necessary -the patient may initially appear to be stable

(c)        Common life threatening dysrhythmias are premature ventricular contractions, ventricular fibrillation and tachycardia fibrillation

(i)         Initiate aggressive advanced life support management of these dysrhythmias -these patients usually have normal healthy hearts and the chances for resuscitation are excellent

(ii)        Management for a patient in ventricular fibrillation with only basic life support available: Start cardiopulmonary resuscitation (CPR) and transport immediately to Level 3

(iii)       Provide field care as you would for thermal burns once the efforts at managing cardiac status are complete

(d)        Other electrical injuries include:

(i)         Skin burns at entrance and exit sites

(ii)        Surface flame burns (patient's clothing being ignited)

(iii)       Dislocations and/or fractures (due to violent muscle contractions)

(iv)       Internal injuries involving muscle damage and nerve damage

(e)        The first priority at the scene of an electrical injury is to determine if the patient is still in contact with the electrical current

(i)         If so, remove the patient from contact without becoming a victim yourself

(ii)        Handling high-voltage electrical wires is extremely hazardous -special training and equipment are needed to deal with downed wires

(iii)       Never attempt to move wires with makeshift equipment (pieces of wood, tree limbs, and manila rope may conduct high-voltage electricity)

(f)         It is impossible initially to determine the total extent of the damage in electrical burns; all electrical burn patients should be transported to the nearest treatment facility

 

Causes

(1)        Can be caused by high or low voltage

(2)        Direct electrical current (deep injuries)

(3)        Arc burns

(4)        Lightning injuries (less deep injuries)

(a)        People can be hit by lightning and survive.

(b)        Usually briefly unconscious

(c)        May develop arrhythmia or cardiac arrest

(d)        Can be successfully resuscitated

 

Signs and symptoms

(1)        They are burns where electrical energy enters and exits the body.  A burn of exit wound is usually larger.

(2)        Disrupted nerve pathways are displayed as paralysis

(3)        Muscle tenderness, with or without twitching

(4)        Respiratory difficulties or arrest

(5)        Cardiac arrhythmia or arrest

(6)        Elevated BP or low BP with signs of shock

(7)        Restlessness or irritability

(8)        Loss of consciousness

(9)        Visual difficulties

(10)      Fractured bones and dislocations from severe muscle contractions or from falling (can include spinal column)

(11)      Seizures


 

Treatment and transport considerations

(1)        Make certain that you and the patient are in a safe zone.

(a)        DO NOT handle power lines unless you are certain the current is turned off

(b)        If the patient is in contact with electricity, turn off the power before approaching him or her

(c)        Power lines may have up to 50,000 volts.  It is always safer to assume a fallen line is "alive."

(2)        Open and maintain airway

(3)        Provide basic cardiac life support as required.  Use a cardiac monitor as soon as possible.

(4)        Care for spinal injuries, head injuries, and severe fractures

(5)        Evaluate the burn looking for the entrance and exit burn sites

(6)        Remove clothing and assess the burn injury

(7)        Apply dry, sterile dressings to the burn sites

(8)        Care for shock and administer a high concentration of oxygen

(9)        Initiate large bore IV access with IV running open- this will aid in preventing renal failure from muscle damage.

(10)      Transport as soon as possible

(11)      The major problems caused by electrical shock are usually not from the burn.  Respiratory and cardiac arrest are real possibilities.  Be prepared to provide basic cardiac life support measures.

 

Manage the casualty with inhalation burns

Inhalation injuries -classified as carbon monoxide poisoning, heat or smoke inhalation injuries.

 

These injuries account for more than half of the 12,000 burn-related deaths per year

(1)        Asphyxiation and carbon monoxide poisoning -the most common cause of early death associated with burn injury

(2)        A byproduct of combustion and is one of numerous chemicals in common smoke. Its presence is impossible to detect -odorless, colorless, and tasteless.

(3)        Patients quickly become hypoxic (alteration in the level of consciousness is the most predominant sign of hypoxia)

(4)        Treatment: high-flow oxygen by mask

(5)        Begin basic life support ventilation using 100% oxygen if the patient has lost consciousness

(6)        By having the patient breath fresh air, it will take up to seven hours to reduce the carbon monoxide-hemoglobin complex to a safe level -breathing 100% oxygen decreases this time to about 90- 120 minutes. Using hyperbaric oxygen (100% oxygen at 2.5 atmospheres) will decrease this time to about 30 minutes

 

Causes

(1)        Can be caused from fumes or smoke in the air.  You may not be able to smell the fumes!

(2)        May be from stream

(3)        The injury may be worse if inhalation occurred in a confined space

 

Signs and symptoms

(1)        Difficulty breathing (dyspnea)

(2)        Coughing, stridor

(3)        Breath has "smoky" or "chemical" smell

(4)        Black residue in patient's nose and mouth

(5)        Nasal or facial hairs are singed

(6)        There are burns to the head, the face, or the front of the trunk

 

Treatment measures

(1)        Move the patient to a safe area

(2)        Do an initial assessment and supply life support measures as needed

(3)        Administer a high concentration of oxygen (humidified if possible) with a nonrebreather mask

(4)        Care for possible spinal injuries and any other injury or illness requiring care at the scene

(5)        Provide care for shock

(6)        Stay alert for behavioral changes

(7)        If difficulty breathing increases, prepare to intubate.

 

Transportation requirements

(1)        Transport in a position of comfort if other injuries allow it

(2)        Most conscious patients are able to breathe more easily when placed in an upright (seated) position

 

Assess for signs and symptoms of carbon monoxide poisoning

(1)        Evaluate casualty's complains

(a)        Dizziness

(b)        Nausea

(c)        Headache

(2)        Inspect casualty cherry-red colored skin and mucous membranes

(3)        Assess casualty for tachycardia or tachypnea

(4)        Monitor vital signs/airway

 

SUMMARY

 

Determining the severity of a burn requires knowledge of the basic anatomy and physiology of the skin and the signs of first, second, and third degree burns.  Prompt recognition and management of burns, based on this knowledge, will reduce the potential for shock development, burn contamination, and chance of other complications.  Calm professional care will help to limit the physical and emotional consequences to the patient.