Sponsored by Masimo
By Jay MacNeal, DO, MPH, FACEP, FAEMS, NRP
We are taught from a very young age to respect the awesome power of fire. It was employed as a means of renewal and destruction long before humans ever found ways to utilize its fierce strength.
We in public service have a special understanding of how fire can impact one life or millions of lives. In reflecting upon fire as a constant hazard of the trade, let’s review the basics of burn care.
Through the years, burn classifications have evolved. We have recently moved away from the first, second, third and sometimes fourth degree classifications and adopted a designation of superficial, partial thickness and full thickness. These new categories are better descriptors and have helped make the conversation less about degree designation and more about treatment plan.
Superficial burns (first degree) are classified by the American Burn Association as “burns which involve the outermost layer of skin.” These burns are often associated with sunburns and very brief exposure to flames. Generally, they are considered self-limiting.
Best practice indicates running cool but not cold water on the area for about five minutes. Generally one should avoid icing the area in the initial stages to prevent any further cellular damage.
Using ibuprofen, acetaminophen and an over-the-counter topical anesthetic may be helpful (in addition to your Grandma’s recommended aloe vera gel). Superficial burns tend to get better on their own with little to no intervention.
Partial thickness burns (second degree) are described by the ABA as “when the second layer of skin (dermis) is burned.” These burns are more severe and regularly have associated large blisters. They also cause a good deal of swelling and are quite painful.
It is possible to get a second degree burn from sun exposure, but more likely, these occur with direct contact with a heat source.
Full thickness burns (third degree and beyond), according to the ABA “are not minor burns and should be evaluated and treated by a healthcare professional.” These burns, regardless of size, must be taken seriously. They have made their way through all the skin’s protective layers and, by definition, have injured structures beneath.
They can range widely in their presentation, depending on the cause of the burn. Some are charred black, some are blanched white, some are very painful due to exposed nerves, and some are relatively painless because of destroyed nerves.
Each and every one of these burns at the fire scene requires immediate transfer to the hospital and – if feasible – to a designated burn center.
Best treatment for burns
Burns can be tricky and, of course, present a series of potential pitfalls. The first essential basic step is to stop the burning process. This limits the damage and can keep a burn from worsening.
Thinking ahead is very important. If burns are near clothing or jewelry that constricts the skin from swelling, remove these items as soon as possible. A ring on a burned hand can lead to the loss of circulation of a finger. Watches, necklaces and medic alert tags should all be considered potentially hazardous.
Burns to places you can see are somewhat easier to deal with. Keep in mind that burns over the joints and to the hands, toes, face and genitalia have particular concerns. Burns that are circumferential are also major concerns and have a low threshold to transport these patients.
Burns to places you cannot see are also urgent. Inhalation of superheated air is not an uncommon occurrence on the fireground. Pay particular attention to those who occupied the residence or tried to put out the fire before the fire department arrived (e.g., bystanders, residents and law enforcement).
Those who have inhaled superheated air are at a very high risk of burning the very delicate tissues of the upper and lower airways. These tissues will swell like any other burn – however, when they do, it cuts off the airflow. Maintain a very low threshold to intubate these patients while you still can, because once the swelling starts, ventilation can be a life-threatening problem.
Our skin provides many functions for us. It is in fact the largest organ of the body. When that barrier is disrupted, we leave ourselves open to large fluid shifts, difficulty transporting lymph and blood and open our bodies to the outside world, inviting infection.
Simple rules prevent burns and their ensuing effects from worsening:
- Keep the area clean.
- Avoid further damage.
- Keep blisters intact.
- Cover the burn with an occlusive dressing.
- Have a low threshold for initiating care early.
The fireground is a place wrought with hazards, from smoke to overexertion and climate concerns, all the way to structural collapse and burns. We regularly encounter patients who have been kissed by the dragon we seek to contain. These burns often go uncared for or are under-cared for in the immediate circumstances. This practice must change. The sooner burns are treated, the better outcome we can achieve.