The Emergency Management of Severe Burns
At the scene, first aid procedures are often life saving. Basic immediate care can be summarized under the following headings;
1) Personal safety
2) Stop burning process and immediate wound care
3) Care of the Airway and Breathing
4) Intravenous fluid therapy
5) Pain relief
6) Transfer to hospital
Do not risk injury to yourself by attempting to rescue a casualty from a fire until the fire has been dealt with effectively and the risk of re-ignition/explosion has been minimized.
Isolate car electrics which will inactivate electronic fuel pumps enabling effective fire-fighting and minimize the above risks. It may be impossible to extinguish a car fire until an electronic fuel pump has been inactivated.
Remember, following a race incident involving fire, it is likely that there will be other injuries as well as burns, so bear in mind the possibility of cervical spine injuries etc.. and manage the situation accordingly.
Immediate life saving measures in burns
Airway distress due to thermal injury
Carbon monoxide poisoning Give all burn victims oxygen therapy. They will not appear cyanosed in CO poisoning
Stop the burning process
IV access Burns >20% of body surface area need circulatory volume support
Immediate first aid
Remove the casualty from the scene of injury as soon as practical bearing in mind the possibility of other injuries.
Extinguish residual flames either by rolling the casualty or covering with a heavy blanket, coat or rug.
Do not get burned yourself. Beware of spilled fuel.
If clothing is still smoldering or hot, apply copious amounts of cold water.
Clothing saturated with boiling liquids or steam should be removed immediately.
Do NOT remove burnt clothing that is adherent to skin. You will remove the skin as well.
Cover burnt areas with sterile towels or sheets and ensure the casualty is kept warm.
What NOT to do
Do NOT apply wet soaks or ice packs to large burned areas. They will not provide any pain relief for patients with full thickness burns and can cause profound hypothermia and intensify shock.
Use cold soaks only on partial thickness burns less than 10% of body surface area.
Do not break blisters or apply antiseptics.
Management of the airway
All casualties must receive oxygen. Assume carbon monoxide poisoning. A pulse oximeter is useless.
Rapidly examine for signs of smoke inhalation or respiratory thermal injury.
Endotracheal intubation is mandatory if there are any signs of respiratory injury, otherwise swelling of the airways may produce complete airway obstruction. By this stage intubation may be impossible and emergency tracheostomy may be necessary.
Clinical features of smoke inhalation/resp. thermal injury
Soot in nose, mouth or sputum
Immediate wide bore i.v. access is imperative.
Burned casualties lose large volumes of fluid through burned skin and this must be replaced otherwise shock will rapidly occur.
If access is difficult using arm veins, large cannulae can be inserted in the femoral veins in the groins.
Try to avoid cannulation through burned skin.
Signs of shock in burns victims
Presence of extensive full or partial thickness burns
Fast weak pulse
Low blood pressure
Poor peripheral perfusion
Intravenous fluid requirements in burns victims
Determined according to body weight and percentage area burned. Initial fluid 500ml Saline or Hartman`s then;
In the first 4 hours following a burn, the volume of COLLOID required will be;
% burn x body weight (Kg)/2
If > 10% burn, blood transfusion will be needed
Assessment of percentage of burn
The rule of nines
Trunk 18% front & 18% back
Pain relief in burns
Full thickness burns are not painful.
Entonox, may be inadequate in severe partial thickness burns.
Intravenous morphine is often necessary.
Depth of burns
Traditionally described as 1st, 2nd or 3rd degree.
Now more descriptively described as superficial, partial thickness and full thickness burns.
Red skin, no blisters, no swelling. can be very painful but only involve the superficial layer of skin.
Never immediately life threatening unless involving the airway.
Partial thickness burns
Deeper than superficial burns.
Red or mottled skin with blisters and swelling.
Weeping, wet surfaces
> 30% can be fatal
Full thickness burns
Damage to all skin layers. Pale, white or charred skin. may appear leathery.
Broken skin with fat exposed.
> 10% may be fatal.
Transfer to hospital
Immediate transfer of burned casualties to hospital is of paramount importance if complications are to be minimized.
Transfer to a specialised Burns Unit should be considered rather than to the nearest A & E unit in severe injury.
Indications for transfer to a Burns Unit
Partial thickness burns > 20%
Full thickness burns > 5%
Partial or full thickness burns involving hands, feet, face, eyes, ears or major joints.
Electrical or chemical burns
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