11.2 Medical Emergencies: Anaphylaxis, Diabetic Crises, Seizures & Trauma

11.2 Medical Emergencies: Anaphylaxis, Diabetic Crises, Seizures & Trauma

Outpatient ambulatory care encounters a diverse spectrum of acute medical and surgical crises. Medical assistants must possess rapid clinical recognition, sound pathophysiological understanding, and decisive technical execution for acute emergencies including systemic anaphylaxis, acute metabolic diabetic derangements, generalized convulsive seizures, acute traumatic hemorrhage, epistaxis, musculoskeletal fractures, and thermal burns. Prompt, evidence-based intervention stabilizes vital organ function and prevents permanent morbidity or fatal outcomes.

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1. Acute Anaphylaxis: Pathophysiology, Clinical Signs & Epinephrine Administration

Anaphylaxis is an acute, severe, life-threatening systemic Type I IgE-mediated hypersensitivity reaction. It is characterized by rapid onset—frequently within seconds to minutes following antigen exposure—and can lead to fatal upper airway obstruction, bronchospasm, or cardiovascular collapse.

Common Etiologies & Triggers

• Medications: Beta-lactam antibiotics (penicillins, cephalosporins), nonsteroidal anti-inflammatory drugs (NSAIDs, aspirin), radiopaque iodinated contrast media, and biological agents.
• Hymenoptera Venoms: Insect stings from honeybees, yellow jackets, hornets, wasps, and fire ants.
• Foods: Peanuts, tree nuts (walnuts, almonds, cashews), shellfish, crustaceans, fish, cow's milk, hen's eggs, and soy.
• Natural Rubber Latex: Medical gloves, urinary catheters, tourniquets, and vial stoppers.

Immunological Pathophysiology

Initial exposure to an allergen induces plasma cells to produce allergen-specific Immunoglobulin E (IgE) antibodies, which bind to high-affinity Fc receptors on tissue mast cells and circulating basophils (sensitization). Upon re-exposure, the allergen cross-links membrane-bound IgE antibodies, triggering explosive mast cell and basophil degranulation.

+------------------------------------------------------------------------------------------------+
|                                 THE PATHOPHYSIOLOGY OF ANAPHYLAXIS                             |
+------------------------------------------------------------------------------------------------+
| [ALLERGEN EXPOSURE] -> Cross-links IgE on Sensitized Mast Cells & Basophils                    |
|                                                                                                |
| [CHEMICAL MEDIATOR RELEASE] -> Massive release of Histamine, Leukotrienes, Prostaglandins      |
|                                                                                                |
| [SYSTEMIC PATHOPHYSIOLOGICAL RESPONSES]:                                                       |
|   * Vascular Endothelium -> Profound systemic vasodilation & massive capillary leakage (Shock) |
|   * Upper Airway -> Laryngeal edema & pharyngeal swelling (Airway Compromise / Stridor)        |
|   * Lower Airway -> Bronchial smooth muscle constriction & mucus plugging (Wheezing / Dyspnea)  |
|   * Integumentary -> Cutaneous vasodilation & sensory nerve activation (Hives / Pruritus)      |
|   * Gastrointestinal -> Smooth muscle hypermotility & cramping (Nausea / Vomiting / Diarrhea)  |
+------------------------------------------------------------------------------------------------+

Multi-System Clinical Manifestations

• Integumentary System (90% of cases): Generalized urticaria (hives) presenting as intensely pruritic, raised erythematous wheals; diffuse cutaneous flushing; pruritus; and angioedema (rapid subcutaneous swelling affecting the lips, tongue, uvula, periorbital tissues, hands, and feet).
• Respiratory System (85% of cases): Laryngeal edema producing hoarseness, globus sensation (feeling of throat closing), and high-pitched inspiratory stridor; lower airway bronchospasm producing severe dyspnea, tachypnea, chest tightness, diffuse expiratory wheezing, and cyanosis.
• Cardiovascular System: Profound hypotension resulting from systemic vasodilation and plasma extravasation; compensatory tachycardia; weak, thready pulse; diaphoresis; dizziness; syncope; and cardiac arrest.
• Gastrointestinal System: Severe spasmodic abdominal cramping, nausea, forceful vomiting, and explosive watery diarrhea.
• Central Nervous System: Intense anxiety, apprehension, feeling of impending doom, confusion, and loss of consciousness.

Emergency Pharmacotherapy: Epinephrine Protocols

EPINEPHRINE (ADRENALINE) IS THE ABSOLUTE FIRST-LINE MEDICATION OF CHOICE IN ANAPHYLAXIS. There are no absolute contraindications to epinephrine in a life-threatening anaphylactic emergency. Epinephrine acts as a physiological antagonist against inflammatory mediators through triple adrenergic stimulation:

1. Alpha-1 Adrenergic Receptor Stimulation: Produces intense peripheral vasoconstriction, reversing systemic hypotension, increasing coronary perfusion pressure, and reducing mucosal edema in the upper airway (relieving laryngeal edema and stridor).
2. Beta-1 Adrenergic Receptor Stimulation: Increases myocardial contractility (positive inotropic) and heart rate (positive chronotropic), restoring cardiac output.
3. Beta-2 Adrenergic Receptor Stimulation: Induces rapid bronchial smooth muscle relaxation (bronchodilation) and inhibits further release of histamine and leukotrienes from mast cells.

+------------------------------------------------------------------------------------------------+
|                           EPINEPHRINE AUTOINJECTOR DOSING & ADMINISTRATION                     |
+-------------------+--------------------+------------------------+------------------------------+
| Patient Category  | Body Weight Range  | Epinephrine Dose       | Concentration / Route / Site |
+-------------------+--------------------+------------------------+------------------------------+
| **Adult Dose**    | >= 30 kg (>= 66 lbs)| **0.3 mg**             | 1:1,000 (1 mg/mL) IM into    |
| (e.g., EpiPen)    |                    |                        | ANTEROLATERAL THIGH          |
+-------------------+--------------------+------------------------+------------------------------+
| **Pediatric Dose**| 15 to 30 kg        | **0.15 mg**            | 1:1,000 (1 mg/mL) IM into    |
| (e.g., EpiPen Jr) | (33 to 66 lbs)     |                        | ANTEROLATERAL THIGH          |
+-------------------+--------------------+------------------------+------------------------------+
| **Infant Dose**   | < 15 kg (< 33 lbs) | **0.01 mg/kg**         | 1:1,000 (1 mg/mL) IM into    |
| (Manual Syringe)  |                    | (Exact weight-based)   | ANTEROLATERAL THIGH          |
+-------------------+--------------------+------------------------+------------------------------+

Technical Administration Guidelines for Epinephrine

• Anatomical Site: Administer exclusively into the ANTEROLATERAL ASPECT OF THE THIGH (Vastus Lateralis muscle). Intramuscular injection into the vastus lateralis achieves significantly higher, more rapid peak plasma drug concentrations compared to administration into the deltoid muscle or subcutaneous adipose tissue.
• Technique: Hold the autoinjector firmly with the orange/black tip pointing down. Remove the safety cap. Position the device at a 90-degree angle against the outer thigh (can be administered through clothing if necessary). Push firmly until the device clicks/fires. Hold firmly in place for 3 full seconds (or 10 seconds depending on manufacturer guidelines) to ensure complete drug delivery, remove, and massage the site for 10 seconds.
• Repeat Dosing: If symptoms fail to resolve or continue to deteriorate, a second dose of epinephrine must be administered 5 to 15 minutes after the initial dose.
• Secondary / Adjunctive Therapies (Administered ONLY AFTER Epinephrine):
  • Call 911 / Activate EMS immediately.
  • Place the patient supine with lower extremities elevated (unless respiratory distress dictates sitting upright).
  • Administer high-flow supplemental oxygen ($100%$ via NRB mask at $10-15\text{ L/min}$).
  • Establish large-bore IV access for rapid $0.9%$ Normal Saline crystalloid resuscitation.
  • Antihistamines: Diphenhydramine ($25-50\text{ mg}$ IV/IM) and Famotidine ($20\text{ mg}$ IV) to relieve urticaria and pruritus (Note: Antihistamines do NOT treat bronchospasm or shock and must NEVER be used as a substitute for epinephrine).
  • Inhaled Bronchodilators: Albuterol nebulizer ($2.5-5.0\text{ mg}$) for persistent lower airway wheezing.
  • Corticosteroids: Methylprednisolone ($125\text{ mg}$ IV) or oral Prednisone to prevent delayed biphasic anaphylactic reactions (which can recur 4 to 12 hours after the initial event).

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2. Diabetic Emergencies: Hypoglycemia vs. Hyperglycemia & DKA

Diabetes mellitus involves defective insulin secretion, insulin resistance, or both. In the outpatient clinic, medical assistants must rapidly differentiate between acute hypoglycemia (insulin shock) and severe hyperglycemia / diabetic ketoacidosis (DKA).

+------------------------------------------------------------------------------------------------+
|                      DIABETIC CRISES COMPARISON: HYPOGLYCEMIA vs. HYPERGLYCEMIA / DKA          |
+---------------------+-----------------------------------+--------------------------------------+
| Clinical Feature    | Hypoglycemia (Insulin Shock)      | Hyperglycemia & DKA (Diabetic Coma)  |
+---------------------+-----------------------------------+--------------------------------------+
| **Blood Glucose**   | **< 70 mg/dL** (Severe: < 54 mg/dL)| **> 250 to 600+ mg/dL**              |
+---------------------+-----------------------------------+--------------------------------------+
| **Onset Speed**     | **Rapid & Sudden** (minutes/hours)| **Gradual & Insidious** (days/weeks) |
+---------------------+-----------------------------------+--------------------------------------+
| **Skin & Moisture** | **Pale, cool, diaphoretic, clammy**| **Flushed, warm, dry, poor turgor**  |
+---------------------+-----------------------------------+--------------------------------------+
| **Breathing**       | Normal or shallow                 | **Kussmaul respirations** (deep, rapid)|
+---------------------+-----------------------------------+--------------------------------------+
| **Breath Odor**     | Normal / No unusual odor          | **Fruity, sweet, acetone odor**      |
+---------------------+-----------------------------------+--------------------------------------+
| **Neurological**    | Shakiness, tremors, anxiety,      | Drowsiness, extreme lethargy, stupor,|
|                     | irritability, dizziness, confusion| progressive coma                     |
+---------------------+-----------------------------------+--------------------------------------+
| **Classic Symptoms**| Intense hunger, palpitations      | Polydipsia, Polyuria, Polyphagia     |
+---------------------+-----------------------------------+--------------------------------------+
| **Primary Cause**   | Excess insulin, skipped meals,    | Omitted insulin doses, infection,    |
|                     | unaccustomed strenuous exercise   | severe physiological stress, trauma  |
+---------------------+-----------------------------------+--------------------------------------+

Hypoglycemia Management Protocols

When capillary blood glucose drops below 70 mg/dL, brain cells (which rely exclusively on glucose for energy) become starved of fuel, producing rapid neuroglycopenic symptoms and sympathetic adrenergic discharge.

The Clinical "Rule of 15" for Conscious Patients

For an alert, oriented patient who possesses an intact gag reflex and is capable of safely swallowing:

1. Administer 15 grams of fast-acting simple carbohydrates orally:
   • $4\text{ fl oz}$ ($1/2\text{ cup}$) of fruit juice (e.g., orange juice, apple juice) or regular (non-diet) soda.
   • 3 to 4 commercial glucose tablets.
   • 1 tube ($15\text{ g}$) of oral glucose gel.
   • 5 to 6 hard candies (e.g., LifeSavers).
   • 1 tablespoon of granulated sugar or honey.
   • Note: Avoid chocolate, candy bars, or milk because dietary fats significantly delay gastric emptying and slow glucose absorption.
2. Wait 15 minutes with the patient resting quietly.
3. Recheck capillary blood glucose using a calibrated glucometer.
4. Repeat Treatment if Necessary: If blood glucose remains $<70\text{ mg/dL}$ or symptoms persist, administer an additional 15 grams of simple carbohydrates and recheck in 15 minutes.
5. Post-Stabilization Nutrition: Once blood glucose rises above $70\text{ mg/dL}$, if the patient's next scheduled meal is more than 1 hour away, provide a complex carbohydrate and protein snack (e.g., peanut butter with whole-wheat crackers, cheese and crackers, or half a meat sandwich) to maintain glycemic stability and prevent rebound hypoglycemia.

Emergency Protocol for Unresponsive or Uncooperative Patients

• STRICT SAFETY RULE: NEVER administer oral liquids, food, or oral glucose gel to an unconscious patient, a seizing patient, or a patient unable to swallow. Doing so causes airway obstruction and pulmonary aspiration.
• Emergency Actions:
  1. Activate 911 / Emergency Medical Services immediately.
  2. Position the patient in the Left Lateral Recovery Position to protect the airway against aspiration.
  3. Administer Glucagon:
     • Parenteral Glucagon: Administer 1 mg Intramuscularly (IM) or Subcutaneously (SC) (0.5 mg for pediatric patients weighing $<20\text{ kg}$). Glucagon stimulates hepatic glycogenolysis, releasing stored glucose into the bloodstream within 10 to 15 minutes.
     • Intranasal Glucagon (Baqsimi): Administer 3 mg single spray into one nostril. Does not require active inhalation.
  4. Intravenous Dextrose: If licensed clinical personnel have established IV access, administer $25\text{ to }50\text{ mL}$ of $50%$ Dextrose in Water (D50W) as a slow IV push.

Hyperglycemia & Diabetic Ketoacidosis (DKA) Management

In severe insulin deficiency (blood glucose $>250-600\text{ mg/dL}$), the body cannot utilize glucose and begins catabolizing adipose tissue into free fatty acids. The liver metabolizes these fatty acids into ketone bodies (acetoacetic acid, beta-hydroxybutyric acid, and acetone), causing metabolic ketoacidosis.

• Clinical Manifestations: Classical triad of Polydipsia (extreme thirst), Polyuria (osmotic diuresis causing massive fluid loss), and Polyphagia (hunger); severe dehydration with dry mucous membranes; Kussmaul respirations (rapid, deep, labored breathing designed to blow off carbon dioxide and compensate for metabolic acidosis); distinctive fruity or acetone breath odor; abdominal pain; nausea and vomiting; and progressive diabetic coma.
• Emergency Management:
  • Activate EMS (911) for urgent hospital admission.
  • Maintain airway and administer supplemental oxygen.
  • Check capillary blood glucose and urine dipstick for ketones and glucose.
  • Provider-directed management: Massive IV fluid resuscitation with $0.9%$ Normal Saline ($1-2\text{ L}$ in the first 1-2 hours) to correct severe dehydration, followed by continuous low-dose Regular Insulin IV infusion and potassium monitoring.
• The Clinical "When in Doubt" Rule: If a diabetic patient presents with acute confusion, altered mental status, or weakness and blood glucose cannot be measured immediately, always treat for hypoglycemia first (administer oral glucose if conscious, or glucagon/IV dextrose). Hypoglycemia causes irreversible cerebral neuronal death within minutes, whereas brief transient hyperglycemia is far less acutely lethal.

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3. Seizure Management Protocols & Status Epilepticus

A seizure is a transient paroxysm of uncontrolled, synchronous electrical discharges across cerebral neurons resulting in sudden neurological dysfunction, altered consciousness, and involuntary motor activity.

Generalized Tonic-Clonic (Grand Mal) Seizure Phases

1. Aura Phase (Warning): Sensory premonition preceding the seizure (unusual olfactory sensation, visual flashing lights, epigastric rising sensation, auditory hallucination).
2. Tonic Phase (Rigidity): Sudden loss of consciousness, sustained generalized muscular contraction, rigid extension of limbs, jaw clenching (tongue biting), vocalization ("ictal cry" caused by forced air through vocal cords), and transient apnea with cyanosis ($10-20\text{ seconds}$).
3. Clonic Phase (Convulsion): Violent, rhythmic, synchronous bilateral muscular jerking and spasms, copious oral foaming/salivation, and potential urinary or fecal incontinence ($1-3\text{ minutes}$).
4. Postictal Phase (Recovery): Cessation of convulsions followed by deep sleep, severe fatigue, headache, muscle soreness, and gradual recovery of orientation over 10 to 30 minutes.

+------------------------------------------------------------------------------------------------+
|                                ACUTE SEIZURE MANAGEMENT PROTOCOLS                              |
+---------------------------------------------------+--------------------------------------------+
| MANDATORY ACTIONS (WHAT TO DO)                    | STRICTLY PROHIBITED ACTIONS (WHAT NOT TO DO)|
+---------------------------------------------------+--------------------------------------------+
| - Stay calm and NOTE THE EXACT START TIME.        | - **DO NOT RESTRAIN** the patient or hold  |
| - Guide patient gently to the floor.              |   limbs down (causes fractures/tears).     |
| - Move sharp furniture and equipment away.        | - **DO NOT PUT ANYTHING IN THE MOUTH**     |
| - Place soft padding or folded jacket under head. |   (no bite blocks, spoons, or fingers).    |
| - Loosen tight neckwear (collars, ties, scarves). | - **DO NOT give oral liquids or pills**    |
| - Turn patient onto side (**Recovery Position**)    |   until completely alert and responsive.   |
|   to prevent aspiration and tongue obstruction.   | - **DO NOT perform chest compressions**    |
| - Remain with patient until full orientation.     |   unless patient is in cardiac arrest.     |
+---------------------------------------------------+--------------------------------------------+

Indications for Activating 911 / EMS for Seizures

While established epileptic seizures lasting under 2 to 3 minutes do not always require emergency transport, the medical assistant must call 911 immediately under any of the following critical conditions:

• The seizure lasts longer than 5 minutes (defines Status Epilepticus, a life-threatening medical emergency causing severe cerebral hypoxia, neuronal destruction, hyperthermia, and cardiac dysrhythmias).
• A second seizure occurs immediately without the patient regaining full consciousness between episodes.
• It is the patient's first known seizure or the patient has no documented history of epilepsy.
• The patient is pregnant, diabetic, or has suffered significant trauma or head injury during the fall.
• The seizure occurs in water (submersion/aspiration risk).
• Normal breathing does not resume, or the patient remains completely unresponsive after convulsions cease.

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4. Trauma, Hemorrhage Control, Epistaxis, Musculoskeletal & Burn Care

External Hemorrhage Control

• Types of Bleeding:
  • Arterial Bleeding: Bright red, oxygenated blood spurting under pulsatile arterial pressure. Most dangerous; rapid exsanguination occurs in minutes.
  • Venous Bleeding: Dark red, deoxygenated blood flowing in a steady, non-pulsatile stream. High volume, easily controlled.
  • Capillary Bleeding: Slow, oozing red blood from superficial abrasions; clots spontaneously.
• Stepwise Hemorrhage Control Protocol:
  1. Direct Pressure: Apply firm, continuous, direct pressure directly over the bleeding wound using a sterile gauze dressing. Maintain pressure for at least 5 to 10 minutes without lifting the dressing.
  2. Pressure Dressing: Apply a sterile roller bandage (conforming gauze or elastic wrap) firmly over the dressing to maintain continuous hemostasis.
  3. Layering Rule: If blood soaks through the initial dressing, DO NOT remove the soaked dressing (removing it strips away newly forming fibrin clot matrices). Apply additional sterile gauze pads directly on top of the original dressing and continue firm pressure.
  4. Elevation: Elevate the bleeding extremity above heart level while maintaining direct pressure (provided no fracture is suspected).
  5. Arterial Tourniquet: If catastrophic arterial extremity hemorrhage cannot be controlled with direct pressure, apply a commercial windlass tourniquet 2 to 3 inches proximal to the wound (never over a joint). Tighten until bleeding stops and distal pulse vanishes. Write the exact application time (TK: HH:MM) on the patient's forehead or tourniquet band. Never loosen or remove a tourniquet once applied; removal must be performed by emergency surgical teams.

Epistaxis (Nosebleed) Management

• Anatomical Types: Anterior epistaxis (90% of cases, arising from Kiesselbach's plexus on the anterior nasal septum; easily managed) vs. Posterior epistaxis (arising from sphenopalatine artery; severe, profuse, common in elderly hypertensive patients; requires emergency packing/cautery).
• Emergency Management Protocol:
  1. Instruct the patient to sit upright and lean slightly forward.
  2. Rationale: Leaning backward causes blood to drain down the posterior pharynx into the stomach, inducing severe nausea, vomiting, and potential airway aspiration.
  3. Instruct the patient to pinch the soft, fleshy lower portion of the nose (both nostrils) firmly against the nasal septum using the thumb and index finger continuously for 10 to 15 full minutes while breathing through the mouth.
  4. Apply an ice pack or cold compress across the bridge of the nose and forehead to promote local reflex vasoconstriction.
  5. Instruct the patient not to blow their nose, bend over, or lift heavy objects for several hours following bleeding cessation.
  6. If bleeding persists beyond 15 to 20 minutes of continuous pressure, notify the provider for anterior nasal packing or chemical silver nitrate cauterization.

Musculoskeletal Injuries & Splinting Protocols

• Injury Classifications: Fractures (closed vs. open/compound with bone protruding through skin), Sprains (stretching/tearing of ligaments connecting bone to bone), Strains (stretching/tearing of muscles or tendons connecting muscle to bone), and Dislocations (displacement of bone ends from a joint articulation).
• The RICE Protocol for Acute Soft Tissue Injuries:
  • R - Rest: Protect and immobilize the injured musculoskeletal structure; eliminate weight-bearing.
  • I - Ice: Apply cold packs wrapped in a thin towel for 20 minutes at a time, every 2 to 3 hours during the first 24 to 48 hours. Induces vasoconstriction, reduces interstitial edema, decreases inflammatory mediator release, and numbs local pain receptors. Never apply ice directly to bare skin.
  • C - Compression: Apply an elastic bandage (e.g., ACE wrap) wrapped distally to proximally with even, snug tension to support injured ligaments and limit swelling. Ensure wrap is not overly tight.
  • E - Elevation: Elevate the injured extremity above the level of the heart to promote gravity-assisted venous return and lymphatic drainage, minimizing edema.
• Principles of Emergency Splinting:
  1. Splint the injured extremity in the exact anatomical position in which it was found; never attempt to realign, straighten, or reduce a fracture or push exposed bone ends back into a wound.
  2. The splint must immobilize the joint above AND the joint below the fracture site (e.g., a forearm fracture requires immobilizing both the wrist and the elbow joints).
  3. Neurovascular Assessment (CSM): Evaluate and document Circulation (distal pulses and capillary refill), Sensation (numbness/tingling), and Motor function (finger/toe movement) BOTH BEFORE AND IMMEDIATELY AFTER applying any splint or bandage. If distal pulses disappear or numbness worsens, loosen the splint immediately.
  4. For open fractures, cover the wound and exposed bone with a sterile, moist saline dressing before applying the splint.

Thermal, Chemical & Electrical Burns

+------------------------------------------------------------------------------------------------+
|                                 BURN DEPTH CLASSIFICATION MATRIX                               |
+-----------------------+-----------------------------+------------------------------------------+
| Classification        | Skin Layers Involved        | Clinical Presentation & Features         |
+-----------------------+-----------------------------+------------------------------------------+
| **First-Degree**      | Epidermis only              | Erythema (redness), dryness, mild edema, |
| *(Superficial)*       |                             | intensely painful, blanching, NO blisters|
|                       |                             | (e.g., typical solar sunburn).           |
+-----------------------+-----------------------------+------------------------------------------+
| **Second-Degree**     | Epidermis & portion         | Erythematous, weeping, moist, **fluid-   |
| *(Partial-Thickness)* | of Dermis                   | filled blisters (bullae)**, severe pain,  |
|                       |                             | hypersensitive to air currents.          |
+-----------------------+-----------------------------+------------------------------------------+
| **Third-Degree**      | Full thickness: Epidermis,  | Leathery, hard, dry, translucent, waxy   |
| *(Full-Thickness)*    | Dermis, into SubQ tissue,   | white, charred black, or brown eschar.   |
|                       | muscle, or bone             | **Painless at center (insensate)** due   |
|                       |                             | to destroyed sensory nerve endings.      |
+-----------------------+-----------------------------+------------------------------------------+

The Rule of Nines for Adult Total Body Surface Area (TBSA)

The Rule of Nines divides the adult body surface area into anatomical regions assigned multiples of $9%$ to rapidly estimate burn severity:

• Head and Neck: 9% ($4.5%$ anterior, $4.5%$ posterior)
• Anterior Trunk (Chest & Abdomen): 18%
• Posterior Trunk (Upper & Lower Back): 18%
• Right Upper Extremity (Entire Arm): 9% ($4.5%$ anterior, $4.5%$ posterior)
• Left Upper Extremity (Entire Arm): 9% ($4.5%$ anterior, $4.5%$ posterior)
• Right Lower Extremity (Entire Leg): 18% ($9%$ anterior, $9%$ posterior)
• Left Lower Extremity (Entire Leg): 18% ($9%$ anterior, $9%$ posterior)
• Perineum / Genitalia: 1%
• Total Body Surface Area: $9 + 18 + 18 + 9 + 9 + 18 + 18 + 1 = 100%$.

Emergency Burn Management Guidelines

• Stop the Burning Process: Extinguish flames, remove smoldering clothing (do NOT peel away clothing melted or adhered to burned skin), and remove constricting rings, watches, and tight clothing before tissue edema develops.
• Thermal Burn Cooling: Cool the burn immediately with clean, cool running water for 10 to 20 minutes. NEVER USE ICE, ICE WATER, BUTTER, OIL, OR GREASY OINTMENTS. Ice induces intense vasoconstriction, deepening tissue ischemia and causing frostbite necrosis; butter and grease insulate tissue, trapping heat and fostering bacterial infection.
• Dressing: Cover burned areas with a clean, dry, sterile non-adherent dressing or clean sheet.
• Chemical Burns: Brush off dry chemical powders first using gloved hands; immediately flush affected skin with copious volumes of running water for at least 20 to 30 continuous minutes (for chemical eye exposure, irrigate eyes continuously from inner canthus to outer canthus).
• High-Voltage Electrical Burns: Turn off the power source before touching the patient. Electrical burns produce extensive hidden internal tissue destruction, cardiac arrest (V-fib), and fractures from violent tetanic muscle contractions.
• Criteria for Immediate 911 EMS Activation & Burn Center Referral:
  • Second-degree burns involving $>10%$ TBSA in adults ($>5%$ in children/elderly).
  • Third-degree burns of any size.
  • Burns involving critical anatomical structures: face, eyes, ears, hands, feet, major joints, or genitalia/perineum.
  • Suspected inhalation injury (facial burns, singed nasal hairs, soot in sputum, carbonaceous cough, stridor).
  • Electrical, lightning, or severe chemical burns.

Medical Emergency Action Protocols & Triage Reference