Emergency Care of the Burn Patient

Management of the Burn Victim at the Scene

For the health care providers who are in the front line, the firefighters, the EMT's, the first thing to remember is to Stop the Burning Process! This may sound trivial but believe it or not burn victims, wrapped in blankets, have been brought into the emergency room still smoldering. Also if you try to put supplemental oxygen on someone who is still on fire you can make the fire explode.

For flame burns, smother the fire with water or a blanket. The health care providers in the field can limit the extent of the injury. Make sure the fire is out and remove burned clothing.

For scald injuries cool the area with water immediately, within 30 seconds of the injury. If you cool a scald injury with water later than 30 seconds, you will have no effect on the extent of injury. After cooling the burn, keep the patient warm and dry.

For chemical burns wash the burn with copious amounts of water. Rather than trying to remember specific chemicals and their neutralization just remember to flush every chemical injury with huge amounts of water. Many of these chemicals will produce more heat if you put only a small amount of water on them, so it is very important to remember that you must flush with copious amounts of water in order to dilute the effects of the chemical. The most dramatic example are alkaline or acid burns to the eye. You must flush the eye out immediately, because if you wait until the victim can be transported to the emergency room, it will be too late, the damage will be done.

Tar, asphalt and melted plastics are treated a little differently because the material can be very difficult to remove. These materials can retain heat for a very long period of time. If you have a patient with a tar burn cool the tar off and leave it in place. These can be removed in most local emergency rooms with chemicals. It can be very difficult to remove, the materials can be very sticky and more damage and pain may be inflicted if removed improperly. One other thing to remember is, when you have a situation like the man in the picture, is to assure an adequate airway.

Most people killed in America by electricity are killed by low voltage current. These victims don't die of their burn injuries, they die from cardiac dysrhythmias, usually ventricular fibrillation. At the scene of an accident, if someone is down, make sure they are not still in contact with the electrical current before you touch them or you can become part of the accident as well. Many of these people are resusitatable, with only a few minutes of CPR or maybe a counter shock will restart the heart.

With high voltage current, the skin resistance is lowered and the victim can get profound injuries from the electricity. Electricity does not travel over the surface of the skin, because the surface tension of the skin is very high. The current tends to enter the body through a relatively small opening, travels deep through the body then exits through a small opening.

This is a typical entrance wound to the hand. This man grabbed a high voltage wire and received the shock through the base of the thumb. This is what the wound looked like in the emergency room.

This is what it looked like after debridement. You can see extensive damage of all of the muscles of the thumb and extending down into the forearm. You can see where a fasciotomy was required to release the pressure.

This is an exit wound, which does not appear to be very significant, but this man's foot had to be amputated because of the extensive muscle necrosis.

Electrical shock may result in unconsciousness, convulsions, loss of memory and orthopedic injuries. Spine fractures may result from tetanic contractions of muscles induced by high voltage current. The victim must have spinal stabilization and cervical collars placed.

After the source of the burn has been eliminated, treat the patient, not the burn! Do not focus on the burn. You can have a very large burn and you won't die within the first hour from your burn injury, but you may die from an obstructed airway in just a few minutes. You can die from a ruptured spleen or you can die from a fractured pelvis, those are the types of injuries that require immediate attention.

Remember the burn patient is a multiple trauma patient. Just like with any other trauma patient you begin with airway, breathing and circulation!

Statistically, people are far more likely to die from an inhalation injury than from burn wounds. Historically, in catastrophes involving fires in large public buildings, most of the people who died did not die from burn injuries. They died from carbon monoxide poisoning and inhalation injury. If you respond to fires with victims, that should be the primary concern.

This is the kind of injury that obviously will require endotrachial intubation. This man has extensive facial burns, upper airway injury and an inhalation injury. He will require intubation not only for oxygenation but also for airway protection.

There are mainly three types of airway injuries:

• Carbon monoxide poisoning
• Inhalation injury above the glottis
• Inhalation below the glottis
• Any victim, burned in a closed area, like a house fire, should be presumed to have an inhalation injury until proven otherwise.

The most common type of airway injury is carbon monoxide poisoning, which may often present with very few symptoms. Carbon monoxide is a byproduct of incomplete combustion of fuels. Carbon monoxide has a 200 times greater affinity for hemoglobin than oxygen. As carbon monoxide binds to the hemoglobin molecule, it prevents the red blood cell from transporting oxygen. As the levels of carboxyhemoglobin increase the patient may develop myocardial and cerebral hypoxia. The most common signs are central nervous system complications: confusion, loss of memory and headache. Anyone unconscious at the scene of a fire should be presumed to have a carbon monoxide injury. The only way to treat a carbon monoxide accident is with immediate application of high flow oxygen at the scene of the fire.

The injuries above the glottis are quite common due to the capacity of the nasopharynx to dissipate heat to the nose, throat and mouth. The resulting thermal injury can cause edema which can present within minutes to hours. These are the types of injuries that can progress to airway obstructions. Those are the people that need to be intubated to protect their airway.

Inhalation injuries of the lungs or injuries below the glottis, may be clinically asymptomatic for the first 48 hours. These people could have normal arterial blood gas levels, a normal chest X-ray, but the next day they get into respiratory distress. These people need to be intubated and treated like someone who has adult respiratory distress (ARDS). When you suspect an inhalation injury, these patients must be watched very closely.

Care of those with evidence of inhalation injuries

Associated injuries are very common with burn injuries. Explosions are common in fires; people jump out of burning buildings; people get burned in automobile accidents. Remember that an unconscious patient is unconscious for a reason other than the burn injury.

This little girl was admitted to the burn center not because of her burn injuries but because of her black eye. This is an absolute indication for referral to the child protection agency. Child abuse is a prevalent problem in infants and children and should be considered in the assessment of every burned child.

The water line pattern may be an indication of abuse if the pattern does not match the story of how the child was burned.

The principles for trauma care are the same for burn victims. If you need to start IV's through burned tissue you can, but you must not tape them in place because the tape will not stick, instead, suture the IV's in place. You can splint fractures that also involve burns, but you must remember to check circulation which may be at risk after splinting due to swelling. Don't be so intimidated by the burn wound that you don't treat the associated trauma.

Keep burn victims warm, they can get hypothermic very quickly. When you loose the outer surface of your skin you lose the ability to regulate your own body temperature. Keep them dry . If you put fluid on them it will cause heat to be evaporated. Do not give a burn victim anything to drink or eat for the first 24 hours. There is a great potential for burn victims to vomit. All pain medication should be given intravenously. Intramuscular medications are not adequately absorbed in the early period following a burn. Titrate intravenous narcotics to achieve pain control.

Please send the initial patient history along with the patient. By the time they arrive at a burn center there is the possibility that they will be intubated and/or sedated. Communication will be difficult at best. Any information that can be sent with the patient will be very helpful in treating the patient.

*DISCLAIMER This site is designed as an introduction to thermal injury for emergency medical technicians, medical students and physicians in training. It is not a comprehensive guide to thermal injury. As such the information may not be sufficient to address specific patient problems and these should be handled by physicians familiar with the specific clinical details pertinent to the individual patient. We invite comments from all users of this site.