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Medical Education Division |
Operational Medicine 2001
Field Medical Service School
Student Handbook
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BURN CASUALTIES FMST 0402 17 Dec 99
TERMINAL LEARNING OBJECTIVE (S): 1.
Given a burn casualty in a combat environment (day and night), and
standard Field Medical Service Technician supplies and equipment, manage burn
casualties per the references. (FMST.04.02) ENABLING
LEARNING OBJECTIVES: 1. Without the aid of reference materials and given a list of burn classifications and treatments, select the proper treatment for the type of burn, per the student handbook. (FMST.04.02a) 2. Without the aid of reference materials, using the Rule of Nines, estimate the percent of body surface area burned, per the student handbook. (FMST.04.02b) 3. Without the aid of reference materials, using the Rule of Palms, estimate the percent of body surface area burned, per the student handbook. (FMST.04.02c) 4. Without the aid of reference and given FMST MOLLE Medic bag and a simulated burn casualty, identify, treat, and monitor the casualty, per the student handbook. (FMST.04.02d) OUTLINE: A.
BACKGROUND INFORMATION 1.
HISTORY / PREVALENCE a.
Thermal burns are not an uncommon injury on the modern battlefield. They
can result from exposure to flame weapons and devices (napalm and white
phosphorous), or from explosions from fuel sources (gasoline, diesel, and jet
fuel). b.
The severity of the burns experienced by the patient will vary greatly,
depending on the source of the burn, the amount of time the patient was exposed
to the agent, and the location of the burn. B.
ANATOMY
AND PHYSIOLOGY OF THE SKIN
a.
Skin
serves many functions: 1.
Thermoregulation
– assists the body in maintaining normal temperature 2.
Protection: a)
The skin
protects the body from heat and cold b)
The skin
prevents the body from losing excessive amounts of fluids and electrolytes c)
The skin
prevents the entrance of bacteria, fungi, and chemicals from entering the body 3.
Secretion: a)
Sweat -
to help maintain body temperature b)
Sebum –
an oily substance that helps lubricate and moisten the skin 4.
Sensory
Reception a)
Pain b)
Touch c)
Temperature d)
Pressure
a.
Epidermis 1.
Is the
superficial protective layer of the skin 2.
Composed
primarily of dead cells containing keratin, which waterproofs and toughens the
skin b.
Dermis 1.
Lies
underneath the epidermis 2.
Is
thicker and deeper than the epidermis 3.
Functions: a)
Regulation
of temperature b)
Supply
nutrition to the epidermis 4.
Contains
the following structures: a)
Blood
vessels – which nourish both the dermis and the living portion of the
epidermis b)
Afferent
Nerve Endings – respond to tactile (touch), pressure, temperature, tickle, or
pain sensations c)
Hair
follicles d)
Sebaceous
glands e)
Sweat
glands c.
Hypodermis 1.
The
deepest layer of the skin 2.
The
hypodermis is responsible for binding the dermis to the underlying organs 3.
Composed
mostly of fibrous connective tissue and adipose cells 4.
Functions: a)
Store
lipids b)
Insulate
and cushion the body c)
Regulate
temperature C.
CLASSIFICATIONS
OF BURNS
a.
The depth
of the burn: 1.
First
Degree Burn / Superficial Burn a)
Definition
– a burn that involves only the epidermis b)
Sign /
Symptoms 1)
Skin is
dry and erythematous 2)
Pain to
site 3)
The
burned area blanches with pressure 4)
Edema (if
present) will be minimal 2.
Second
Degree Burn / Partial Thickness Burns a)
Definition
– a burn in which the epidermis is burned through and the dermis is damaged b)
Sign /
Symptoms 1)
Deep,
intense pain 2)
Skin is
moist 3)
Skin will
be hyperemic in color 4)
Blister
formation 5)
Edema
will be moderate 3.
Third
Degree Burn / Full Thickness Burn a)
Definition
– a burn in which all the layers of the skin are damaged b)
Sign /
Symptoms 1)
Skin has
a dry, leathery appearance 2)
The skin
can range in color from pale yellow to cherry red, brown, or carbon black 3)
Severe
pain around periphery of burn, but little to no pain near center of burn 4)
Will see
First and Second Degree burns surrounding the Third Degree Burn b.
Total
Body Surface Area (TBSA) affected by the burn 1.
Burns can
be categorized by the percentage of body surface damaged by the burn 2.
Two
Methods for Estimating the Total Body Surface Area (TBSA) affected by Burns: a)
Rule of
Nines (RON) 1)
The Rule
of Nines divides the TBSA into areas compromising 9% or multiples of 9%, except
for the peritoneum which is equal to 1% TBSA. 2)
The Rule
of Nines is an estimate and is most useful for adults and children over the age
of 10. 3)
The Rule
of Nine’s is helpful for estimating the TBSA of large or regularly shaped
burns. b)
Rule of
Palm’s (ROP) 1)
The Rule
of Palm’s assumes that the palm size of the patient represents approximately
1% of the TBSA. TBSA is then
estimated by approximating the number of “palms” it would take to completely
cover the burn. 2)
The rule
of Palm’s is helpful for estimating the TBSA of small or irregularly formed
burns. D.
TYPES OF
BURNS
a.
Definition
– burns in the upper and lower airways, caused by the inspiration of heat,
toxic, chemicals, smoke, or other gases. b.
Cause 1.
Heat
inhalation 2.
Inhalation
of toxic chemicals or smoke 3.
Inhalation
of carbon monoxide gas c.
Signs /
Symptoms - 1.
Dyspnea 2.
Tachypnea 3.
Coughing 4.
Stridor 5.
Hoarseness 6.
Sooty
Sputum 7.
Abnormal
Lung Sounds – crackles, wheezes, or rhonchi may be present 8.
Burns to
the oral and/or pharyngeal mucous membranes 9.
Singed
nasal hairs 10.
Facial
burns 11.
Tachycardia d.
Treatment 1.
Maintain
the patient’s ABC’s a)
Adjunctive
airways may be used if respiratory distress occurs b)
Endotracheal
intubation for severe respiratory distress c)
Emergency
cricothyroidotomy if edema causes airway obstruction 2.
Administer
humidified oxygen if available 3.
Place the
patient in an upright position 4.
Evacuate
a.
Definition
– tissue injury caused by exposure to extreme radiant heat b.
Causes 1.
Scalding
liquids 2.
Steam or
other hot gases 3.
Contact
with hot objects 4.
Fire c.
Sign /
Symptoms 1.
Signs and
symptoms with thermal burns are the same as for First, Second, and Third degree
burns d.
Treatment 1.
Remove
the patient from the source of injury 2.
Maintain
the patient’s ABC’s 3.
Remove
any material that could continue the burning process (oils, burned clothing,
etc.) 4.
First
degree burns – immersion in cool water or the application of cool compresses 5.
Second
degree burns – initially, place in cool water or apply cool compresses.
Dry, bulky dressing can be applied later. 6.
Administer
oxygen therapy if available 7.
Protect
the patient from heat loss and possible hypothermia 8.
Treat for
shock
a.
Definition
– occur when the patient comes in direct contact with caustic chemical agents b.
Cause 1.
Acids 2.
Alkalies 3.
Petroleum
Based Products 4.
Military
Causes: a)
Napalm b)
White
Phosphorous c.
Sign /
Symptoms – are influenced by the length of contact, the concentration of the
chemical, and the amount of chemical 1.
Erythema 2.
Edema 3.
Blisters 4.
Tissue
necrosis 5.
Pain at
exposure site d.
Treatment 1.
Irrigate
burned area with copious amounts of water 2.
Burns due
to concrete or lime should not be irrigated with water.
The mixture of these powders with water creates a corrosive substance
that will further burn the patient. Brush
the powder off the patient instead. 3.
Burns due
to phenol (carbolic acid) should not be irrigated with water since phenol is not
water soluble. Instead, irrigate
with a lipid-soluble solvent (i.e. polyethylene glycol) 4.
Hydroflouric
acid burns (used in glass etching, dental laboratories, industry, and electronic
plants) are potentially life threatening. Evacuate the patient as quickly as possible 5.
White
Phosphorous a)
Ignites
with air contact – therefore, cover wound with a wet dressing b)
A
solution of sodium bicarbonate may be used to rinse the wound to help neutralize
the resulting phosphoric acid. c)
Rinsing
the wound with a solution of copper sulfate is no longer recommended d)
White
phosphorous wounds may be identified by using a fluorescent blue light – the
white phosphorous will fluoresce and glow bright white. 6.
ELECTRICAL
BURNS a.
Definition
– electrical current, including lightning, can cause severe damage to the
body. The skin is burned where the
energy enters the body and where it flows into a ground.
Along the path of this flow, tissues are damaged due to heat. b.
Cause 1.
Exposure
to electrical current (either AC or DC) 2.
Lightning
Strike c.
Sign /
Symptom 1.
Burns
where the energy enters and exits the body 2.
Difficulty
breathing or respiratory arrest 3.
Irregular
heartbeat or cardiac arrest 4.
Muscle
tenderness 5.
Fasiculations 6.
Convulsions 7.
Fractured
bones 8.
Visual
difficulties d.
Treatment 1.
Maintain
the patient’s ABC’s 2.
Care for
shock 3.
Administration
of oxygen therapy if available 4.
Application
of cool compresses to burn areas 5.
Dry,
sterile dressings to burns 6.
Evacuate E.
TREATMENT
OF BURNS (GENERAL PRINCIPLES)
a.
Second-
and Third- degree burns pose a significant challenge to health care providers in
the field environment because the injury requires massive amounts of fluids to
properly resuscitate a patient. b.
The
Parkland Formula is used to calculate the amount of fluids a burn patient will
require over the initial 24 hours (Note: the clock starts ticking the moment the
burn occurs!) Parkland
Formula:
(Patient’s weight in kg) X (4 cc’s of LR) X (TBSA
of burn) = cc’s of
fluid required / 24 hrs Half of this fluid is to be delivered within the
first 8 hours of the occurrence of the burn injury. The remaining half is then to be delivered over the remaining
16 hours. Example: An 80 kg male reports to the BAS with a second degree burn
covering approximately 40 % of his body (TBSA=40). The burn happened 5 minutes ago. Calculation: (80
kg) X (4 cc’s) X (40 TBSA) = 12,800 cc’s over 24 hours Administration:
a.
12,800 /
2 = 6,400 cc’s in the first 8 hours =
800 cc / hour for 1st 8 hours b.
12,800 /
2 = 6,400 cc’s in the second 16 hours = 400 cc / hour for 2nd 16
hours Example: A 100 kg male presents to the BAS with third degree burns
covering approximately 60 % of his body (TBSA=60). The burn happened 3 hours ago. Calculation: (100
kg) X (4 cc’s) X (60 TBSA) = 24,000 cc’s over 24 hours Administration: a.
24,000 /
2 = 12,000 cc’s in the first 8 hours (but three have already expired, so must
subtract 3 from 8 = 5 hours to infuse) = so, 12,000 cc’s over 5 hours = 2,500
cc / hour for 1st 5 hours b.
24,000 /
2 = 12,000 cc’s in the second 16 hours = 750 cc / hr for the 2nd 16
hours
a.
Initially,
most burns can be irrigated with cool water. b.
Cover
with a dry, sterile, bulky dressing
REFERENCE
(S): 1.
Emergency War Surgery 2.
Brady
Emergency Care
Field Medical Service School
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