The Quick and Dirty Guide to Burn Injuries
The number one concern when treating a burn patient, as with any trauma, is scene safety. As soon as the scene is safe move the patient away from the source of the burn while maintaining spinal precautions (if spinal injury is suspected). If the patient is actively smoldering, the EMT will need to stop the burning process, rapidly.
Severely burnt patient’s rarely die immediately as a result of the burn itself. These patients generally die sometime later, from airway injury or other related trauma. When large areas of skin are lost to the effects of a burn, the patient faces the probability of hypovolemia, hypothermia, and severe infections. The dermis is responsible for maintaining the strength and elasticity of the Integumentary system.
Signs & Symptoms of Possible Inhalation Injury
Immediate death from burns usually occurs from inhalation of the toxic gases or smoke that are emitted during the fire, rather than burns from the flames.
- Black sputum/mucus being expelled by the patient
- Patient’s voice may be hoarse or absent
- Cough with tachypnea
- Breath sounds may reveal stridor or rhonchi
- Altered level of consciousness (ALOC)
- Worsening hoarseness
- Cardiac or respiratory arrest
The above signs and symptoms should be taken as strong indicators that inhalation injury has occurred. Aggressive assessment and treatment are essential to the survival of burn patients’ suffering inhalation injuries.
Burn depth is measured in degrees of severity from superficial to full-thickness
- Superficial burns are pink and slightly swollen from edema. The associated pain is minimal and will often subside as the burn cools. These burns do not blister and affect the epidermis layer only.
Partial Thickness Burns
- Partial thickness burns may be superficial or deep. Superficial partial-thickness burns are painful, red, blistered, moist and more edematous than a first-degree burn.
- Deep partial-thickness burns appear both white and red. They will have a lack of hair to the area and may or may not be painful.
- Partial-thickness burns affect some amount of the dermis, which contains lymph vessels, small blood vessels, sweat glands, collagen bundles, fibroblasts and nerves.
Full Thickness Burns
- Full thickness burns involve the nerves that supply the skin. Therefore, they aren't painful. Color ranges from white to black, and the skin will be dry and leathery. Full-thickness burns extend through the dermis and tend to cause hemolysis, worsening the patient’s condition.
Severe Full Thickness Burns
- Severe full thickness burns (Fourth-degree) burns extend through subcutaneous fatty tissue, which is responsible for maintaining heat, into muscles, larger blood vessels and often bone tissue. This causes rhabdomyolysis and puts the patient at great risk for renal failure, limb loss and death.
- Circumferential full thickness burns represent an additional problem, the stiffening of the skin along with internal edema cut off, venous blood and lymph flow creates a tourniquet effect. Blocked venous and lymphatic flow impedes recovery, and the swelling will ultimately cause nerve compression and the blockage of arterial flow.
- In burns encompassing the torso, chest expansion will become restricted. These patients require rapid, safe transport for escharotomy to restore circulation and to maintain adequate tidal volume.
What is Rhabdomyolysis?
Rhabdomyolysis is the breakdown of muscle fibers that leads to the release of muscle fiber contents (myoglobin) into the bloodstream. Myoglobin is harmful to the kidney and often causes kidney damage.
Rule of Nines
Total Burn Area Calculations
The extent of the burn should be determined in all burns greater than (>) superficial (1st degree) thickness by using one of two methods.
- Small or limited splatter burns can be estimated using the rule of palms. Using this method: The size of the patient’s palm = 1% BSA (BSA-Body Surface Area)
- Larger burns > superficial, are calculated in the prehospital setting using the rule of nines. This method splits the body into several major parts.
The head (front and back, including the face and neck), anterior chest, abdomen, upper back, lower back (including the buttocks), the front of each leg, the back of each leg, and each arm represent 9% BSA each, and the groin represents 1% BSA. The rule of nines is used in an adjusted form with children and infants due to their anatomical differences, with the head representing a higher BSA and the legs a lower BSA proportionally with decreased age, where an infant’s head represents 19% BSA and each leg totals only 13.5%.
Note: the difference in percentages for the adult and pediatric heads due to their size (Pediatric 18%; Adult 9%)
- Chemical burns are most frequently the result of industrial accidents. However, with more than 25,000 chemicals with a potential to cause burns in common use, chemical burns can occur in a variety of settings. Burns from chemical sources aren't frequently seen, however, they carry a serious risk of death and disability. If the chemical is relatively weak, a chemical burn may occur over an extended period of time before the patient realizes they’re being burned.
- Chemical burns tend to be deeper than thermal burns, although the skin may not appear as damaged. Assessment of chemical burns based on appearance. For example, a painful hydrochloric acid burn will appear brown and similar to a third degree burn, while silver nitrate, which generally doesn’t cause a burn with brief contact, will stain the skin black.
Note: Some chemical burn processes won’t stop without a neutralizing agent. This means EMS will be transporting a patient who remains actively burning.
Chemicals can be divided into two broad categories:
Acids and alkalis (bases)
- Strong acids with a pH of 2 or less, such as hydrochloric acid, cause coagulative necrosis at the point of skin contact. While extremely painful, this allows for some protection of structures deep to the necrotic site.
- Alkalis, such as cement, break apart cell structures, loosening tissues through liquefaction necrosis. Alkali burns are deeper. For this reason, they are generally more severe than acid burns.11
Patients presenting with chemical burns will need to be irrigated copiously with water for an extended period of time, often up to 30 minutes and sometimes up to two hours (Follow local protocol). Different chemicals require different lengths of irrigation and types of neutralizing agents.
If possible, the provider should locate the chemical and consult the MSDS, and should transport the chemical label to the hospital with the patient.
Once EMS providers realize they’re dealing with a chemical burn, they should don the appropriate personal protective equipment (PPE) and brush off any dry chemical found on the patient to prevent further burns once irrigation has begun.
This is best accomplished by using a chemical shower or a hose. Take care to contain all runoff in containers. This will avoid burns to providers from the used contaminated water. All contaminated clothing will need to be removed prior to or during irrigation. The patient shouldn’t be immersed in water because that might spread the chemical to unaffected parts of the body.
Irrigation may need to be continued en route to the hospital but should be done only if fluids can be contained (i.e., in a bucket). The provider should take care to prevent hypothermia in the patient by covering unaffected areas.
Chemical burns to the eyes should be continuously irrigated during transport. If only one eye is affected, take care to avoid contaminating the unaffected eye. Hold the eye open manually and remove contact lenses with a clean gloved hand as soon as possible. Irrigate the eye by running normal saline through IV tubing or through a nasal cannula when both eyes are affected.
EMS providers should administer high-flow oxygen to all patients with major burns involving the airway. Keep in mind that chemical airway burns irritate mucosa and manipulating the airway with adjuncts, may cause the airway to swell significantly. Airway adjuncts that are blindly inserted, such as the Combitube, are generally contraindicated.
Request immediate ALS back-up for definitive airway control.
Take special note if a patient is burned with one of three specific chemicals:
- Clorox - should be first flushed with milk, followed by water irrigation.
- White phosphorous - burn sites should be soaked in water and transported to the hospital for neutralization by copper sulfate.
- Hydroflouric acid - used in glass etching and in methamphetamine production, is highly toxic and causes death at a lower percentage BSA than most burns.
Electrical burns may not appear as gruesome as thermal burns, but they have a great amount of internal injury with only entrance and exit wounds visible. A patient who has electrical burns may have no exit wounds or may have multiple exit wounds. Tissues between wounds are damaged as the current travels through the body. The current takes the paths of least resistance; usually nerve pathways and vasculature.
The extent of damage to tissues is determined by the voltage. Domestic electricity tends to be considered low voltage. These electrocutions create small, deep contact burns at entry and exit points. Low voltages can be lethal and may create such dysrhythmias as asystole, atrial fibrillation and ventricular fibrillation. Electrocution may cause sudden respiratory failure by paralyzing respiratory muscles.
High-voltage burns will either be true electrocutions or arc burns. True high-voltage electrocutions are greater than 10,000 V and are associated with fourth-degree burns, necrosis, fatal dysrhythmias, limb loss, rhabdomyolysis and renal failure.
- Electrocutions >70,000 V are considered unsurvivable.
A patient with an arc burn has experienced a thermal burn that may have been upwards of 4,500° F, which is hot enough to set the patient’s clothing on fire.
Electrical Current Types and Dysrhythmia associated:
- DC (Direct Current) electrocutions usually cause Asystole
- AC (Alternating Current) electrocutions usually cause ventricular fibrillation
- Lightning strike electrocutions can deliver > 100,000,000 volts
Scene safety is especially important when dealing with burns. Fumes should be considered hazardous, liquids caustic and electrical wires live until absolutely cleared.
Inhalation Injuries Kill, if aggressive treatment and transport are not initiated, rapidly!
Suspicion of inhalation injury requires immediate administration of hi-flow O2 and aggressive airway control. At the EMT level, when intubation isn’t possible; consider airway adjuncts. Some airway devices such as the Combitube, or King, may be considered; but are seldom effective. An airway adjunct placed in the esophagus may not divert oxygen into a trachea, that’s extremely swollen from smoke inhalation/burns.
Burns of the airway cause rapid swelling and chemical irritants that may be present in house fire smoke will cause mucosal irritation, rapidly increasing edema in the airway.
- Histamine release may cause severe bronchospasm, worsening the patient’s ability to maintain their airway.
It’s a no win situation, if an EMT suspects a burn patient has also sustained an inhalation injury, requesting immediate ALS back-up or Air medical, can make all the difference in this case. It is essential to get these patients intubated and ventilated with 100% O2 and potentially CPAP.
Continuous positive airway pressure has shown to be effective following inhalation injuries by decreasing the production of pulmonary edema. This helps keep the airways open and increases the amount of oxygen that remains in the lungs at the end of each exhalation.
Burnt areas of the body have decreased lymphatic flow and often don’t have an intact barrier against infection.
- When BSA is less than 10%, gauze moistened with sterile water may be applied to the burn for patient comfort.
The major cause of death from thermal burns is infection, so EMS providers should:
- Cover all larger burns with dry sterile bandages to minimize the risk of infection as much as possible.
- EMT providers should also cover burn patients a clean dry sheet and keep them warm.
Note: Once the total burn surface area (BSA) of a patient is equal to 30%, inflammatory response may become systemic.
An inadequate amount of fluids in the burn patient leads to end-organ hypoperfusion, which can lead to ischemia.
Decreased plasma volume, increased afterload and decreased cardiac contractility cause a decrease in cardiac output.
Burn shock is a combination of distributive, hypovolemic and cardiogenic shock and may be countered by treating for traditional shock symptoms and ALS interventions such as, fluid administration and pain medication administration. Requesting ALS intercept would possibly help your patient most, if inhalation injury has in fact occurred.
- Hypotension is a late sign of burn shock.
Note: The patient’s pulse is a more accurate measure of their shock status, and patients with burns of more than 15% BSA should be suspected of shock and treated accordingly.
The severity of a burn injury can range from the brief contact of scalding hot water to a chemical burn that continues to inflict injury until a neutralizing agent is applied in the hospital.
Treatment is focused on:
- Halt the burning process
- Protect the airway
- Prevent further potential disability
- Maintain homeostasis (treat for shock)
- Control airway with advanced adjuncts if needed
- Administer high flow O2, BVM if needed
- Establish IV x2 if possible for severe burns, don't insert IV in burnt tissue if possible, (consider IO)
- Providing pain control, per MCP.
Check out this video series on Burns, they are informative and only 10 minutes each!
Now that you’re a pro at burn patient care, don’t forget to smoke MedicTests.com’s Quick & Dirty Quiz!