4.4 Protocol 7: Burns, Protocol 8: Carbon Monoxide / Hazchem & Protocol 22: Industrial Accidents
Key Takeaways
- Protocol 7 grades burns by the patient's condition, not by the burn itself: 7-E-1 is Person on fire (ECHO) and the DELTA codes are multiple victims, arrest, unconscious, not alert, and difficulty speaking between breaths; burns over 18% BSA (7-C-3) and significant facial burns (7-C-4) are CHARLIE.
- Dispatch burn dressing instructions require clean, dry sheets or dressings; dispatchers must strictly prohibit ice, ice water, butter, or greasy ointments.
- Protocol 8 mandates immediate evacuation when multiple occupants in a single structure present with concurrent headache, nausea, or dizziness, treating the scene as toxic gas/carbon monoxide until cleared.
- Protocol 22 enforces industrial scene safety via Lockout-Tagout (LOTO): machinery power must be physically locked out before extrication or patient contact is permitted.
- Amputated body parts must be wrapped in clean, saline-moistened or dry gauze, placed into a sealed waterproof plastic bag, and placed on ice—never directly submerged in water or placed directly on bare ice.
4.4 Protocol 7: Burns, Protocol 8: Carbon Monoxide / Hazchem & Protocol 22: Industrial Accidents
Quick Answer: Protocol 7 triages thermal, chemical, and electrical burns using the Rule of Nines. The MPDS grades the patient, not the wound: 7-E-1 Person on fire is the ECHO code; the DELTA codes are 7-D-1 Multiple victims, 7-D-2 Arrest, 7-D-3 Unconscious, 7-D-4 Not alert, 7-D-5 Difficulty speaking between breaths; and the clinically "critical" burn descriptors sit at CHARLIE — 7-C-1 Fire with person inside, 7-C-2 Difficulty breathing, 7-C-3 Burns greater than 18% body area, 7-C-4 Significant facial burns. Burn dressings must be clean and dry; dispatchers must strictly forbid ice, cold water soaks, or ointments. Under Protocol 8, if multiple people in a building present with concurrent illness, carbon monoxide poisoning must be presumed, triggering immediate evacuation and scene hazard warnings. In Protocol 22 (Industrial Accidents), Lockout-Tagout (LOTO) is mandatory before touching victims caught in machinery, and amputated parts must be wrapped in damp gauze, sealed in a dry plastic bag, and placed on ice, never directly in water or on bare ice.
1. Protocol 7: Burns (Thermal, Chemical, Electrical)
Burns represent severe tissue destruction resulting from thermal energy, caustic chemicals, electrical currents, or radiation. The EMD must rapidly identify respiratory airway compromise, calculate burn extent, and coach immediate pre-hospital wound care.
Depth Classification
- Superficial (1st Degree): Damage confined to the epidermis. Skin is erythematous, dry, and painful without blisters (e.g., mild sunburn). Excluded from total BSA calculations.
- Partial Thickness (2nd Degree): Extends through the epidermis into the dermis. Characterized by intense pain, erythema, weeping fluid, and hallmark blister formation.
- Full Thickness (3rd/4th Degree): Complete destruction of all epidermal and dermal layers, extending into subcutaneous fat, muscle, or bone. The wound appears leathery, waxy white, translucent, or charred black. Because sensory nerve endings are destroyed, the center of the burn is often insensate (painless), though surrounded by acutely painful partial-thickness margins.
The Dispatch Rule of Nines for Body Surface Area (BSA)
To estimate total body surface area burned, MPDS utilizes the Rule of Nines:
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| RULE OF NINES: ADULT VS. PEDIATRIC |
| |
| Anatomical Region Adult (% BSA) Infant / Toddler |
| ------------------------------------------------------------------- |
| Head & Neck 9% 18% |
| Anterior Torso (Chest/Abdomen)18% 18% |
| Posterior Torso (Back/Lumbus) 18% 18% |
| Each Upper Extremity (Arm) 9% (x2 = 18%) 9% (x2 = 18%) |
| Each Lower Extremity (Leg) 18% (x2 = 36%) 13.5% (x2 = 27%) |
| Perineum / Genitalia 1% (not counted) |
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Critical Burn Criteria and Their MPDS Codes
Burn-centre criteria and MPDS determinant levels are related but not identical. A patient requires transport to a verified burn centre when any of the following is present — note which of them the MPDS codes at CHARLIE rather than DELTA:
- Extensive Surface Area (MPDS 7-C-3): Partial or full-thickness burns exceeding 18% BSA in adults, or >10% BSA in children and elderly patients.
- Critical Anatomical Locations (MPDS 7-C-4 for significant facial burns): Burns involving the face, neck, hands, feet, major joints, or genitalia/perineum (due to severe functional contractures and cosmetic disfigurement).
- Inhalation Injury Signs (MPDS 7-C-2 Difficulty breathing; 7-D-5 if the patient can only speak between breaths): Flame or smoke exposure in an enclosed structure, accompanied by singed facial or nasal hair, soot in the mouth or sputum, stridor, hoarseness, or brassy coughing. Airway edema can cause total laryngeal closure within hours.
- Circumferential Burns: Burns encircling an entire limb or the thoracic cage. As full-thickness burned skin loses elasticity and contracts (forming a rigid eschar), tissue edema beneath the eschar generates compartment syndrome in extremities or mechanical asphyxiation from restricted thoracic expansion.
Dispatch Dressing Protocols: Clean, Dry, and Non-Adherent
The EMD instructs callers through exact burn care steps:
- Extinguish the Burning Process: Direct the caller to smother flames with a coat or blanket, roll the victim on the ground, or briefly pour cool water over smoldering clothing (<1 to 2 minutes only).
- Clean, Dry Dressings Only: Cover the burned areas with clean, dry sheets, towels, or sterile dressings.
CARDINAL BURN CARE PROHIBITIONS:
"NEVER apply ice, ice packs, butter, or ointments!
Ice causes severe vasoconstriction and necrosis.
Greases trap heat and introduce severe infection.
USE CLEAN, DRY SHEETS ONLY!"
Why Ice and Ointments Are Lethal
- Ice / Ice Water Hazard: Applying ice to burned tissue induces profound microvascular vasoconstriction, worsening local ischemia and converting salvageable partial-thickness burns into permanent full-thickness necrosis. Furthermore, because extensive burns destroy the body's thermoregulatory barrier, cold packs rapidly induce systemic hypothermia, accelerating the trauma triad of death.
- Grease and Ointment Hazard: Lay callers frequently want to apply butter, petroleum jelly, mayonnaise, or antibiotic ointments. These substances form an insulating barrier that seals residual heat deep inside tissue. At the burn center, surgeons must painstakingly scrape off these contaminations, causing intense pain and tissue destruction.
Chemical Burn Management
For chemical exposures, the EMD provides specific decontamination coaching:
- Dry Powder Chemicals (e.g., lime, lye): Instruct the caller to brush off all dry chemical powder before applying water. Adding water directly to dry lime creates an exothermic reaction that produces severe secondary thermal burns.
- Liquid Chemicals: Flush continuously with copious amounts of running water for a minimum of 15 to 20 minutes, while simultaneously removing contaminated clothing.
2. Protocol 8: Carbon Monoxide / Hazchem & Toxic Gases
Toxic gas inhalations represent insidious emergencies where the primary danger extends beyond the patient to encompass bystanders, family members, and arriving rescue personnel.
Carbon Monoxide Pathophysiology
Carbon monoxide (CO) is known as the "silent killer" because it is completely colorless, odorless, tasteless, and non-irritating to mucous membranes. Produced by incomplete combustion (malfunctioning furnaces, gas water heaters, wood stoves, portable generators, vehicle exhaust):
- Hemoglobin Affinity: Carbon monoxide binds to the oxygen-binding sites of hemoglobin with an affinity 200 to 250 times greater than oxygen, forming carboxyhemoglobin ($COHb$).
- Cellular Asphyxiation: Not only does $COHb$ prevent oxygen transport, it shifts the oxyhemoglobin dissociation curve to the left (Haldane effect), preventing the release of remaining oxygen to tissues. Furthermore, CO binds to intracellular cytochrome c oxidase, halting mitochondrial ATP generation.
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| CARBON MONOXIDE MASS CASUALTY RULE |
| |
| If MULTIPLE occupants in a single structure present with concurrent: |
| - Flu-like symptoms (Headache, nausea, dizziness, fatigue) |
| - Syncope, confusion, or simultaneous pet illness / collapse |
| SUSPECT CARBON MONOXIDE OR TOXIC GAS UNTIL PROVEN OTHERWISE! |
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Non-Discretionary Evacuation and Scene Safety Directives
When toxic gas is suspected, the EMD must enforce mandatory protective actions:
- Immediate Evacuation: Direct all occupants to leave the building immediately and assemble at an outdoor safe location in fresh air.
- Strict Prohibition of Re-Entry: Callers must be explicitly ordered not to re-enter the building for any reason—neither to retrieve pets, wallets, or coats, nor to attempt to open additional windows.
- Responder Hazard Warnings: The EMD must alert incoming fire and EMS units that a hazardous gas environment is suspected, ensuring firefighters do not enter without Self-Contained Breathing Apparatus (SCBA) and multi-gas monitors.
3. Protocol 22: Industrial / Machinery Accidents
Industrial and agricultural accidents involve high-mass, high-torque machinery capable of producing catastrophic blunt trauma, mangled extremities, traumatic amputations, and profound structural entrapment.
Lockout-Tagout (LOTO) Scene Safety Doctrine
Before a dispatcher can instruct a caller to assist a worker caught in machinery, the EMD must verify that the machine is entirely disabled:
- The Mechanical Danger: Automated presses, hydraulic rams, conveyor belts, and agricultural power take-off (PTO) shafts often store immense hydraulic, pneumatic, or gravitational energy. If an emergency stop button is pressed without a physical Lockout-Tagout (LOTO) interlock, cycling or sudden pressure release can pull rescuers directly into the machinery or crush the victim further.
- EMD Directive: Instruct the caller to confirm that electrical disconnects are pulled and main valves shut off before approaching the entrapment zone.
Traumatic Amputation Management
When an industrial accident severs an appendage (finger, hand, foot, or limb), the EMD coordinates dual clinical priorities: life support for the patient, and anatomical preservation of the severed part for surgical reimplantation.
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| PROPER CARE OF AN AMPUTATED APPENDAGE |
| |
| Step 1: Wrap severed part in clean, sterile saline-moistened gauze |
| Step 2: Place wrapped part into a waterproof plastic bag & seal tight |
| Step 3: Place sealed plastic bag into a cooler ON ICE |
| |
| CRITICAL: NEVER put tissue in direct water or directly on bare ice! |
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The Disastrous Errors of Direct Water or Ice Contact
- Direct Water Immersion: Lay callers often drop a severed finger directly into a glass of water. This is catastrophic. Hypotonic tap water causes massive intracellular fluid uptake, leading to severe cellular edema, tissue maceration, and irreversible endothelial destruction that renders microsurgical vascular re-anastomosis impossible.
- Direct Bare Ice Contact: Placing amputated tissue directly on bare ice causes cellular freezing, frostbite, and ice crystal formation that shreds delicate digital arteries and nerves. The tissue must always be insulated within a dry, sealed plastic barrier that rests on a bed of ice.
4. Comparative Triage Matrix: Protocols 7, 8, and 22
| Assessment Domain | Protocol 7: Burns | Protocol 8: Hazchem / CO | Protocol 22: Industrial Accidents |
|---|---|---|---|
| Life Threat | Airway swelling, hypovolemic shock, sepsis | Cellular asphyxiation, multi-occupant toxicity | Exsanguination, entrapment, crush syndrome |
| Highest Codes | 7-E-1 Person on fire (ECHO); 7-D-1 multiple victims; 7-D-2 arrest; burns >18% BSA = 7-C-3 | 8-D-1 Arrest; 8-D-2 Unconscious; 8-D-5 Multiple victims | 22-D-1 Mechanical/machinery entrapment; 22-D-4 Confined space |
| Key Scene Directive | Extinguish flames; clean dry dressings | Immediate evacuation; strictly NO re-entry | Verify power disconnected (Lockout-Tagout) |
| Prohibited Actions | Ice, cold baths, butter, ointments | Re-entering building for pets or belongings | Placing amputated tissue directly on ice/water |
5. Realistic Dispatch Dialogue: Industrial Entrapment & Amputation
EMD: "9-1-1, what is the address of the emergency?"
CALLER: "Precision Metalworks, 880 Forge Way, in the stamping bay!"
EMD: "What is the phone number you're calling from?"
CALLER: "555-9011!"
EMD: "Okay, tell me exactly what happened."
CALLER: "A worker's arm got caught in the mechanical roller press! The press crushed his arm
and severed his hand! Blood is pouring out!"
EMD: [LAUNCHES DELTA 22-D-1 RESPONSE -> DIRECTS IMMEDIATE LIFE SUPPORT]
"Is the machine completely shut off and powered down?"
CALLER: "Yes, we hit the master emergency stop and locked the main breaker!"
EMD: "Good. Is he awake?"
CALLER: "Yes, he's screaming, he's losing a lot of blood!"
EMD: "Listen to me carefully: Paramedics and rescue teams are en route right now.
Do you have a commercial tourniquet in your industrial safety station?"
CALLER: "Yes, we have a trauma kit right here!"
EMD: "Take the tourniquet out. Wrap it around his upper arm, 2 to 3 inches above the cut,
away from the elbow. Pull the strap as tight as you can, then turn the windlass rod
until the bleeding stops completely. Lock the rod in the clip."
CALLER: "Okay, the windlass is locked! The bleeding has slowed right down to a trickle!"
EMD: "Now listen regarding his severed hand: Do not wash it with water.
Wrap the hand in clean, dry or slightly damp gauze. Put the wrapped hand inside a clean
plastic bag and seal the bag shut. Then place that sealed plastic bag on ice inside a cooler.
Do not let the bare hand touch the ice directly. Do you understand?"
CALLER: "Yes! Wrapped in gauze, sealed in a plastic bag, bag placed on ice! Paramedics are here!"
A 35-year-old mechanic suffered second- and third-degree burns across his entire anterior chest, entire abdomen, and both anterior arms. According to the adult Rule of Nines and Protocol 7 triage standards, what is the estimated BSA burned and the appropriate dispatch dressing protocol?
An emergency dispatch center receives a 9-1-1 call from a homeowner reporting that her husband, teenage son, and herself all developed sudden severe headaches, dizziness, and nausea over the past hour, and their family dog just collapsed. What is the mandatory protocol action?
During an industrial lathe accident, a worker experiences a complete traumatic amputation of two fingers. How should the dispatcher instruct the caller to preserve the amputated digits for potential surgical reimplantation?