Burns & Environmental Trauma

Burns are one of the most painful and potentially devastating injuries EMTs encounter. Proper classification, estimation of burn severity, and appropriate initial management can significantly improve patient outcomes.

Burn Classification by Depth

Superficial Burns (First-Degree):

• Affects only the epidermis (outermost skin layer)
• Appearance: Red, dry, no blisters
• Pain: Painful (nerve endings intact)
• Example: Sunburn
• Healing: 3-5 days without scarring
• NOT included in burn area calculations for severity

Partial-Thickness Burns (Second-Degree):

• Extends through the epidermis into the dermis
• Appearance: Red, moist, blisters present, may appear weeping
• Pain: Very painful (exposed nerve endings)
• Example: Scald burns, contact with hot objects
• Healing: 2-4 weeks; deep partial-thickness may scar

Full-Thickness Burns (Third-Degree):

• Destroys the entire dermis and may extend into subcutaneous tissue, muscle, or bone
• Appearance: White, waxy, brown, or charred; dry, leathery (eschar)
• Pain: Painless in the center (nerve endings destroyed), painful at edges where partial-thickness burns surround it
• Example: Prolonged flame exposure, electrical burns
• Healing: Requires skin grafting; significant scarring

Rule of Nines: Body Surface Area Estimation

Quick Estimation Tip: The patient's palm (including fingers) represents approximately 1% of their BSA and can be used to estimate irregular burn areas.

Critical Burns (Require Burn Center Referral)

A burn is classified as critical if any of the following are present:

• Full-thickness burns covering >10% BSA
• Partial-thickness burns covering >20% BSA
• Burns involving the face, hands, feet, genitalia, perineum, or major joints
• Circumferential burns (encircle an extremity or the torso) - risk of compartment syndrome or respiratory compromise
• Inhalation injury (suspected or confirmed)
• Electrical burns (including lightning)
• Chemical burns to critical areas
• Burns in patients with significant pre-existing medical conditions
• Burns with associated trauma (fractures, etc.)

Burn Treatment

1. Stop the burning process - Remove the patient from the source; extinguish flames (stop, drop, roll)
2. Remove clothing and jewelry from the burned area (unless adhered to the skin)
3. Cool the burn - Apply room-temperature or cool water for thermal burns
   • Do NOT use ice or ice water (causes vasoconstriction and worsens injury)
   • Do NOT apply butter, ointments, or home remedies
4. Cover with dry, sterile, non-adherent dressings
5. Prevent hypothermia - Burns destroy the skin's ability to regulate temperature; keep the patient warm with blankets after cooling
6. Pain management - Burns are extremely painful; keep the patient comfortable
7. Monitor for shock - Large burns cause significant fluid loss

Electrical Burns

Electrical burns present unique challenges:

• Internal damage is often far more severe than surface burns suggest - electricity travels along blood vessels, nerves, and muscles
• Always look for entry wound (where current entered) and exit wound (where current left the body)
• Cardiac monitoring is essential - electrical current passing through the body can cause fatal dysrhythmias (ventricular fibrillation, asystole)
• Suspect associated injuries: muscle damage (rhabdomyolysis), fractures from muscle contractions or falls, spinal injuries
• Scene safety is critical - ensure the power source is de-energized before approaching

Chemical Burns

• Dry chemicals: Brush off the dry chemical first with a gloved hand, then irrigate
• Liquid chemicals: Begin immediate, copious irrigation with water for at least 20 minutes
• Remove contaminated clothing during irrigation
• Do NOT attempt to neutralize the chemical (the reaction generates heat and worsens the burn)
• Protect yourself - wear appropriate PPE to avoid secondary contamination
• Note the specific chemical for the receiving facility (bring the SDS/MSDS if available)

Inhalation Burns

Suspect inhalation injury when any of the following are present:

• Singed nasal hairs or eyebrows
• Facial burns (especially around the nose and mouth)
• Sooty sputum (carbonaceous material in sputum)
• Hoarseness or voice changes (laryngeal edema)
• Stridor (high-pitched inspiratory sound indicating upper airway swelling)
• Carbonaceous deposits around the nose and mouth
• History of being in an enclosed space fire

Management:

• This is an airway emergency - early aggressive airway management is critical
• Administer high-flow oxygen via non-rebreather mask at 15 L/min
• Be prepared for rapid airway deterioration as swelling progresses
• Upper airway edema can develop quickly, making airway management increasingly difficult
• Transport to a burn center with early notification