DEFINITIONS (Figure 93)
First-degree burn. This is a burn that involves the outermost layer of skin, the epidermis. It is often quite painful. The skin is reddened, but there is no blister formation. When a large surface area is involved, as with an extensive sunburn, the victim may become quite ill, with fever, weakness, chills, and vomiting.
Second-degree burn. This is a burn that involves the epidermis and portions of the next-deeper layer of the skin, called the dermis, which contains the sweat glands, hair follicles, and small blood vessels. It is usually more painful than a first-degree burn, and blisters are present. Large areas of second-degree injury impair the body’s ability to control temperature and retain moisture. Thus, a severely burned victim loses large amounts of fluid and can rapidly become hypothermic in a cold environment.
Third-degree burn. This is a burn that has penetrated the entire thickness of the skin, and may involve muscle, bone, and so on. It is typically painless because of nerve destruction. The appearance is dry, hard, leathery, and charred. Occasionally, the skin will appear waxy and white with small clotted blood vessels visible as purple or maroon lines below the surface. Because a third-degree burn is usually surrounded by an area of second-degree injury, the edges of the wound may be quite painful. Third-degree burns nearly always require a skin graft for coverage.
Partial-thickness burn. First-degree or second-degree burn.
Full-thickness burn. Third-degree burn.
Inhalation injury. This is a burn that involves any portion of the airway. Inhalation injury occurs when a victim is trapped in a fire and inhales smoke, steam, or superheated air (see page 114).
Figure 93 Burn wound. Note that third-degree (full-thickness) burns completely destroy nerves and are painless.
TREATMENT FOR BURNS
1. Remove the victim from the source of the burn. If his clothing is on fire, roll him on the ground or smother him in a blanket to extinguish the flames. Remove all materials that are hot or burned. If the victim has been burned with chemicals, gallons of water should be used to wash off the harmful agents. If chemicals may be present in an article of clothing, remove it. If the eyes are involved, they should be irrigated copiously. Phosphorus ignites on contact with air, so any phosphorus in contact with the skin must be kept covered with water. Do not attempt to neutralize acid burns with alkaline solutions or vice versa; the resultant chemical reaction may liberate heat and worsen the injury. Stick to irrigation with water. If clothing remains stuck to the skin and does not fall away with irrigation, do not tear the clothing away. Cut around it.
2. Evaluate the airway. Look for evidence of an inhalation injury: burns of the face and mouth, singed nasal hairs, soot in the mouth, swollen tongue, drooling and difficulty in swallowing saliva, muffled voice, coarse or difficult breathing, coughing, and wheezing. If it appears that an inhalation injury has occurred, administer oxygen (see page 431) by face mask at a flow rate of 5 to 10 liters per minute, and transport the victim to a hospital as quickly as possible.
3. Examine the victim for other injuries. Unless the airway is involved or the victim is horribly burned, the burn injury will not be immediately life threatening. In your eagerness to treat the burn, don’t overlook a serious injury such as a broken neck. Control all bleeding and attend to broken bones before applying burn dressings.
4. Treat the burn:
First-degree: A first-degree burn, such as a mild to moderate sunburn, may be treated with cool, wet compresses for 10 to 20 minutes. If the burn is acquired suddenly (as when a child grabs a hot rock), immediate application of very cold water (not solid ice) may help limit the extent of the tissue damage. Oral administration of an antiinflammatory drug, such as aspirin or ibuprofen, may provide considerable relief. For severe sunburn (“lobster body”), the administration of oral prednisone in a rapid taper (80 mg the first day, 60 mg the second, 40 mg the third, 20 mg the fourth, 10 mg the fifth) may be extremely helpful. Corticosteroids should always be taken with the understanding that a rare side effect is serious deterioration of the head (“ball” of the ball-and-socket joint) of the femur, the long bone of the thigh.
Topical corticosteroid creams or ointments are of no benefit in treating a burn wound. Anesthetic sprays that contain benzocaine work for a few hours, but may induce allergic reactions. They should be used sparingly. If no blisters are present, a moisturizing cream (such as Vaseline Intensive Care) will help soothe the skin. Aloe vera gel or lotion seems to promote resolution of extensive first-degree burns. Burnaid first-aid burn gel (Rye Pharmaceuticals), which also comes in an impregnated dressing, contains 2% to 4% melaleuca oil and is advertised to provide relief from the pain of minor burns and scalds.
Second-degree: A second-degree burn should be irrigated gently to remove all loose dirt and skin. This should be done with the cleanest cool water available. Never apply ice directly to a burn; this may cause more extensive tissue damage. Cool compresses may be used for pain relief for 10 to 20 minutes. Mild soap and water may be used to clean the burn.
After the wound is clean and dry, cover it with a soft, bulky dressing made of gauze or cloth bandages, taking care to keep the dressing snug but not tight. If antiseptic cream such as silver sulfadiazine (Silvadene) is available, it should be applied under the dressing. Silver sulfadiazine should not be used on the face or in victims who are pregnant, infants, or nursing mothers with children younger than 2 months. An alternative is mupirocin ointment or cream, or bacitracin ointment. A nonadherent dressing layer directly over the antiseptic is easier to change than coarse gauze. Another excellent covering is Spenco 2nd Skin underneath an absorbent sterile dressing. Spenco 2nd Skin is an inert hydrogel composed of water and polyethylene oxide. It absorbs fluids (so long as it doesn’t dry out), which “wicks” serum and secretions away from the wound and promotes wound healing. Other occlusive hydrogel-type dressings are NU-GEL (preserved polyvinyl pyrrolidone in water) and Hydrogel, which can absorb up to 2 ½ times its weight in exuded (from the wound) fluids. Yet another covering for a burn is a layer of petrolatum-impregnated Aquaphor gauze under a dry (absorbent) gauze dressing.
Do not apply butter, lanolin, vitamin E cream, or any steroid preparation to a burn. These can all inhibit wound healing, and may facilitate infections with increased scarring.
Dressings should be changed each day to readjust for swelling and to check for signs of infection. Be certain to keep burned arms and legs elevated as best possible, to minimize swelling and pain.
Blisters should not be opened, unless they are obviously infected and contain pus (this will generally not occur until 24 to 48 hours after the burn injury). If a blister remains filled with clear fluid, it is an excellent covering for the wound and will minimize fluid loss and infection. There is no rush to remove charred skin from a burn wound. As the wound matures and dressings are changed, gentle scrubbing will lift off dead tissue.
A victim with large areas of second-degree burns may need to be treated for shock (see page 60).
Third-degree: A third-degree burn should be irrigated gently and may be cleansed with mild soap and water. It should then be covered with antiseptic cream or ointment or Spenco 2nd Skin, and a dry sterile dressing.
If a first-degree burn involves more than 20% of the body surface area and the victim suffers from fever, chills, or vomiting, a physician evaluation is required. If a second-degree burn involves a significant portion of the face, eyes, hands, feet, genitals, or an area greater than 5% of the total body surface area, a physician evaluation is required. Body surface area can be estimated using the “rule of nines” (Figure 94). For an adult, each upper limb equals 9% of total body surface area (TBSA), each lower limb equals 18%, the anterior and posterior trunk equal 18% each, the head and neck combined equal 9%, and the genital/groin area (perineum) equals 1%. For a small child, each upper limb equals 9% of TBSA, each lower limb equals 14%, the anterior and posterior trunk equal 18% each, the head and neck combined equal 18%, and the perineum equals 1%. Another method to estimate involved body surface area is the “palm of hand” rule: The surface area of the victim’s palm with the fingers represents approximately 1% to 1.5% of his TBSA. All third-degree burns are serious and should be seen by a physician.
Figure 94 Rule of nines for body surface area estimate.
Wet versus Dry Dressings
If the burn surface area is small (less than 10% of total body surface area), cool, moist dressings (not ice) may be used to initially cover the burn wound. These often provide greater pain relief than do dry dressings. If the surface area involved is large, however, dry, nonadherent dressings should be used, to avoid overcooling the victim and introducing hypothermia (see page 305). Because the skin is the major thermoregulatory organ of the body, it is difficult for an extensively burned victim to control his body temperature, so great care must be taken when wetting down such a person. If the victim begins to shiver, the cooling is too extreme.
Fluid Replacement
A person who has suffered an extensive burn will rapidly become dehydrated. Because water quickly shifts from the blood volume into the tissues of the body, the injured skin cannot retain moisture, and associated immune suppression leads to overwhelming infection and shock. Oral rehydration with balanced salt solutions is little help, but in the wilderness, it is usually the only option. Try to get the victim to drink—in sips, if necessary—enough liquid to keep the urine copious and clear (see page 208). If a burned victim cannot drink because his airway is injured, consciousness is altered, weakness prevails, or vomiting is persistent, immediately call for an evacuation.
Antibiotics
Antibiotics are not necessary for burns unless they become infected. This is indicated by the presence of pus, foul odor, cloudy blisters, increased redness and swelling in the normal skin that surrounds the burn, and fever greater than 101°F (38.3°C). If a burn becomes infected, administer dicloxacillin, cephalexin, or erythromycin, and be certain to change all dressings daily. If a person sustains a serious burn that becomes infected after exposure to ocean water, administer ciprofloxacin, doxycycline, or trimethoprim-sulfamethoxazole in addition to the other antibiotic chosen. Blisters that appear to be infected should be “unroofed” and drained, then covered with a proper dressing.
Tar Burn
If a victim is splashed with hot roofing tar or paving asphalt, immediately immerse the affected area in cool water to solidify the tar and limit the burn. If a small area is covered with tar and you cannot reach a physician, you can remove the tar by gently massaging it with repeated coatings of bacitracin or mupirocin ointment, or mayonnaise, which will turn brown as the tar dissolves into it. Do not injure the skin by attempting to roughly peel off the tar. After the tar is removed, treat the burn as described previously. If you cannot dissolve the tar, cover the wound with bacitracin ointment or mupirocin ointment or cream, and a clean dressing.
BURN PREVENTION
1. Obey all posted warnings regarding campfires.
2. Use flame-resistant tents and sleeping bags.
3. Keep all campfires a sufficient distance (minimum 20 feet) from tents and other flammable materials. Create a clear, fuel-free perimeter of at least 3 feet around any campfire or grill. Do not sit too close to a campfire, particularly in windy conditions. Do not allow children to play near a campfire.
4. Do not add lighter fluid, gasoline, kerosene, or any other flammable liquid to a flaming fire or hot coals/embers.
5. Store flammable liquids in approved metal containers that are tightly sealed. Do not fill lamps and stoves with fuel anywhere near intense heat or open flames. Use a funnel to pour flammable liquids, and clean up any spills immediately.
6. Keep a bucket of water within easy reach of a campfire.
7. Thoroughly extinguish the campfire before going to sleep or leaving the campsite.
8. Do not handle camp sauna hot rocks or cook pots without wearing proper hand protection.
9. Do not allow children to handle containers with hot water.
10. Do not set containers of hot water or food on unstable or uneven surfaces.
11. Use battery-operated lights in or near tents or campers.