Burns

Burns are among the most distressing injuries a person can experience. They are often unpleasant in appearance and extremely painful. Burns can be disfiguring and even life threatening. When providing first aid to someone who has been burned, remember good bedside manner: Care for the injured person as well as the burn.

It is important rescuers of burn victims not forget the fundamentals of basic life support. Although a burned individual's pain and emotional distress may be severe, as in all emergency situations the priorities in care are scene safety followed by circulation, airway and breathing (CAB). When establishing if a scene is safe, it is important to determine whether the source of the burn (a fire or hot stove, for example) is still a hazard and respond accordingly. If a person is on fire, he should be encouraged to stop, drop and roll as rescuers attempt to smother or douse the flames. Caregivers should never place themselves at risk of being burned, inhaling smoke or being trapped by fire in order to provide first aid.

Circulation, airway and breathing also warrant special attention in burn victims. Exposure to intense heat can cause airway swelling; smoke inhalation can impair breathing and loss of fluid due to burns might lead to shock, a type of cardiovascular emergency. When assessing airway and breathing, note any coughing or wheezing or the presence of soot, ash or redness around the nose and mouth. These clues can improve a rescuer's understanding of any respiratory symptoms that may be present.

A burn occurs when the body's tissues are subjected to more energy than they can tolerate. This energy can come from chemicals, heat (thermal energy), radiation or electricity. Chemical burns are caused by contact with a caustic chemical. If the chemical is dry, assist the victim in brushing off the substance and consult a Material Safety Data Sheet (MSDS), which should be present wherever caustic chemicals are found. If there is no MSDS available, flush with copious amounts of water. Chemical burns are not particularly common in backcountry settings. Thermal burns, on the other hand, are common, often resulting from accidents involving fires or stoves. Thermal burns may result from contact with flame, a hot solid object such as a camp stove or hot liquid such as boiling water. Thermal burns, though, are not the most common burns experienced by backcountry travelers. That distinction goes to radiation burns. If this is surprising, it may sound even stranger that the source of the radiation is 93 million miles away. It's the sun, of course; it burns more outdoor enthusiasts than all other sources combined. Finally, electrical burns in the outdoors are most often a result of lightning strike (see "Field Medicine," Alert Diver, Summer 2011).

After ensuring the scene is safe and quickly addressing CAB, rescuers should douse a burn with cool water. Either fresh or salt water will do, and the cleanliness of the water is not particularly important since cooling is the goal. This irrigation should continue for at least 15 to 30 minutes. This may sound like a long time, but it is important to stop the burning process in deeper tissues. (Experienced cooks will recognize this principle; it's the same one by which meat keeps cooking after it is removed from the oven.) Clothing, particularly boots or shoes, should be removed immediately to prevent continued exposure.

Once a burn has been thoroughly cooled, a caregiver should begin to assess the injury. There are three criteria that guide assessment: depth, extent and location. Make notes about each of these to pass along to paramedics, nurses or physicians at the next level of emergency care.

Traditionally, burn depths were expressed as either first, second or third degree. This was a source of confusion for many, so those terms are falling out of favor. Burns are now generally classified as superficial, partial thickness or full thickness. Superficial burns are, not surprisingly, the least severe of the three. They are characterized by redness, warmth and sometimes swelling. Partial-thickness burns involve deeper layers of skin tissue and are distinguishable by the presence of blisters and severe pain. Full-thickness burns affect all layers of the skin, destroying nerves and fatty tissue. Full-thickness burns may appear black and charred or white and waxy. They are sometimes described as painless due to the fact that nerve tissue has been destroyed. While this may be technically accurate, full-thickness burns are most often surrounded by areas of partial-thickness burn, and injured persons generally report intense pain.

The extent of a burn is the percentage of total body surface area (TBSA) it covers. A person's palm, including the fingers, is usually equal to about 1 percent of his TBSA; this can help a caregiver estimate a burn's extent.

In addition to the depth and extent of a burn, the particular location on the body should be noted as well. Certain special-function areas warrant particular attention. These include the face, neck, hands, feet, groin and armpits. The face and neck are important due to concerns about the airway; hand, foot and groin injuries can significantly affect quality of life. The armpits merit concern because burns there can result in dangerous fluid loss. Any burn that goes all the way around a limb can potentially impair circulation, so it also deserves special attention.

Once a burn has been thoroughly cooled and assessed, wash it gently with clean, soapy water, rinse thoroughly and pat dry. Do not break intact blisters, but bits of clothing or small areas of obviously dead skin may be trimmed away. Dress and bandage the wound with a nonadherent dressing such as Telfa, Adaptic or 2nd Skin Moist Burn pads. It is also appropriate to use double-antibiotic ointment and a gauze pad, but it's important to ensure a burn is thoroughly cooled before covering it with any dressing. Change dressings daily to check for infection.

Superficial and small partial-thickness burns can usually be managed in the field, but injured people may wish to discontinue a trip due to discomfort. Aloe gel, ibuprofen or topical over-the-counter creams may help relieve symptoms. Sunburn should be covered to ensure it does not burn any further.

Any partial-thickness burn that covers more than 15 percent of a person's body must be evaluated promptly by a physician. The pain from such a burn would be difficult to manage in the field, and the risk of significant fluid loss would be high. Any full-thickness burn also warrants immediate evacuation. The risk of infection, fluid loss and other complications precludes field management.

As with any injury, a burn is easier to prevent than treat. Take care around flames, hot objects, boiling water, electricity and caustic chemicals. Take cover during thunderstorms, and protect yourself from the sun. If you're faced with caring for someone who has been burned, stay calm, ensure the scene is safe, assess CAB, and cool the burn by pouring on water. When in doubt, add more water.


© Alert Diver — Fall 2011