Emergency Burn Treatment

[Jonas Parker]

I'm going to throw this straight at Dr. Baboon. Having watched the Islamofacist would-be bomber burn to a crisp at Scotland's Glascow Airport, I was wondering if there was any appropriate treatment for third-degree burns outside of a hospital burn unit. Suggestions please...

[DrBaboon]

I don't think this will work as a single response, so I'll go into this assuming it will turn into more than one response, adapting to questions and discussions as needed.

I guess the question begins with understanding the kinds of injuries and complications that come from 3rd degree burns.

There's a good chance that someone with burns covering a large part of the body, especially if it involves the face, will have inhaled flame.

Smoke inhalation, carbon monoxide poisoning are possible, even likely.

Internal burns of the mouth and airway, perhaps extending into the lungs are possible.

Securing and maintaining an airway is going to be a high priority if there are facial/oral/airway burns. That airway is often going to be surgical - cricothyroidotomy or tracheotomy. Swelling in the mouth/nose/airway is common, and there is a window of opportunity to establish that airway before you might not be able to do so.

Burned tissue tightens and does not move well.

That has impact in limbs that are burned (loss of movement, constriction, circulatory compromise and nerve pressure resulting in damage, etc.). There are lots of reasons why burn patients have so many surgeries - one is to remove dead tissue, another reason is to cut tissue as it constricts to relieve tension and restore/preserve movement - it's a long process. Other reasons for surgery might include amputation (beyond debriding - I guess the question is whether you can debride something where it eventually becomes an amputation), or potentially skin grafting at well chosen times.

Now consider burns on the chest or neck, and having that tighten up. It's possible to have restriction of chest movement that's sufficient to interfere with breathing. That would also be addressed surgically - escharotomy.

Thermal instability is common in extensive burns.

Fluid loses are substantial, and are usually addressed according to formulas based on estimates of area burned.

Pain control is a huge need - both initially, as well as ongoing.

Even in palliation, and death/dying, analgesia plays a major role.

This is a partial list.

We haven't addressed local care to a burn.

Burn center or not, burns require enormous resources, for a prolonged period.



Realistically, my bias for prolonged austere medicine is that I can see overcoming a blocked airway but not ventilating someone. The kind of blocked airway I can see being appropriate to overcome is local trauma or allergic reaction, where you don't expect deeper airway or pulmonary injury or disease that will persist. I don't think that extensive facial burns/inhaled burns fall into that category, as you must assume pulmonary damage and more complications that will persist (and will likely require ventilation).


The Rule of 9's is a good place to start.


I think limb amputation is going to be more likely in a severe extremity burn, and perhaps should be considered earlier rather than as a last resort, though probably after a patient shows they are more or less stable without deterioration. One definitive procedure is more likely achievable than many smaller procedures, with all the support and resources needed along the way.

Infection is a major source of the final event leading to death among burn patients.

While DIC is possible, it's not that common: http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=15774294&dopt=Abstract

GI complications are more common, and renal failure/dialysis less so:

http://www.medbc.com/annals/review/vol_6/num_1/text/vol6n1p26.htm



As I said, just a start.

Gotta know some of the possibilities for problems and where this might go to have a good discussion.

[DrBaboon]

Rule of 9's (also included in some of the subsequent links in one fashion or another):

http://rad.usuhs.mil/rad/home/peds/child_abuse/tsld031.htm

http://en.wikipedia.org/wiki/Total_body_surface_area

Fluid management:

http://www.totalburncare.com/orientation_burn_shock.htm

http://www.surgical-tutor.org.uk/default-home.htm?core/trauma/burns.htm~right

http://www-cdu.dc.med.unipi.it/ECTC/EBURNS.htm Which also has general assessment principles, and other aspects of management - such as foley catheter placement for monitoring urine output, NG tube placement (makes sense if you are establishing an airway).


This is ambitious stuff.

I don't think anyone has sufficient IV fluids - it probably means being able to make more.


Even getting through the first day or 2 or 3 of care, I think it's either going to become clear (or recognized) that there's a good chance you would not have a positive outcome under prolonged austere circumstances (and perhaps shift gears into a palliative mode) *OR* you have someone doing sort of well on their own *OR* you have arranged somehow to get together with other people and increased the resources and personnel directed to this person's care.


Initial care pretty much has to include airway, fluids and thermal stability.

[Beprepared]

I don't think anyone has sufficient IV fluids - it probably means being able to make more.

Initial care pretty much has to include airway, fluids and thermal stability.

Having had EMS training (I am by no means anything close to a combat medic) one of the things I'm stocking up on is medical equipment. Having IV fluids is paramount, and its as important to my stocks as my ammo. Unless you have a dedicated room for surgery, you have to learn the rules of compromise, doing what you can with what you have. My shop has a large cycle lift, that COULD be pressed into surgical duty, if cloroxed. How ever my surgery would be with book in hand, as most of my dealing with manipulating flesh is starting IVs and surturing.

A third degree burn, as the good Dr has informed us, is never alone. The issues of dying/dead flesh being removed, constant risk of infection to explosed muscle tissue and the tightness/tearing of burn wounds, is just the first round. What are your plans for used equipment/material? You don't want the infection in the skin you just scrubbed off to infect anyone else around. Do you have enough material to cover/cool/protect the skin while it heals? Do you have a way to refill your oxygen that you vic will need? Does anyone even have a home ventilator?

Unfortunetly, in a SHTF or TEOTWAWKI situation, a 3rd degree burn is most likely a death sentance, or a huge burdon on the other members of your group and your supplies. We have triage for a reason.

But I always plan for the worst, that way I am never suprised by it.

[jrayborn]

Great discussion, hate to let it drop off, so how about burns not in the 3rd degree category? Say localized 2n'd degree or even very localized 3rd? I think it is at least to me pretty clear that a large 3rd degree burn that gets to the face is likely with the training most individuals posses, to be a death sentence without professional care ASAP. Looks to be likely a slow painful death at that.


So how about say a child falls on a wood stove, serious burn on a forearm probably not 3rd degree but still serious enough. What would be the recommended products and procedures to have on hand to clean and treat this kind of burn. I am thinking cleaning the wound and preventing infection being the main issues here, but what and how do you recommend going about it for best results?

JR

[tedbo]

Great discussion! Not to hijack your thread,but what is being used for 2nd and 3rd degree burns? I burnt my whole hand back in '72 and some of it was 3rd degree and they gave me some yellow salve. Is this still around or is there a new,improved item available?

It would definitely be worthwhile to have on hand.

[Beprepared]

Having a small measure of medical training (EMT Basic), and have a localized 3rd degree burn on my arm (now fully healed, hair returned) I can offer this advice.

First you need to deal with the thermal damage, get the wound cold, and fast. Cold and wet is the best. Think of it as meat on a grill, if the surface is cooking, the rest is slowly cooking, so you need to cool the wound.

Next you need fluids, cause the body is going to go CRAZY attacking the wound, plasma loss will be significant.

Third you need to clean the wound, this is the hard part. I cleaned my arm every 24 hours, with an antibacterial soap in the shower, heavy lather and a wash cloth to remove scabs, further dead flesh, and clean out estabished infections in the past 24 hours. Let me make this clear, THIS PROCESS WILL HURT. When I did it, I screamed the entire time I was scrubing. There will be bleeding, it needs to be dealt with.

I re-wrapped my wound after cleaning with Neosporin (any good anti-biotic will do, even Iodine, however, Iodine will hurt as much or more than the scrubbing) and a clean set of guaze pads, 3 layers thick, wrapped with guaze.

This went on for about a month, and got strange looks from people as my guaze bandage, by the end of the day, was quite yellow with plasma, but it kept the wound clean and covered.

I hope this answers some of your question.