Burn management

[Alan Halcon]

Here's a new article on burn management.

The topic is tricky, because of varied theories on the subject. Regardless, the Wilderness provides its own unique set of obstacles that should be considered

http://dirttime.com/?p=1249

[Fireguy]

Good article the cleaner the water for cooling the better. Any water is better than not cooling.

[adrenalinemedic]

Alan,

I know you mean well, but I gotta jump in here. Some of the information in your article is incorrect and/or potentially dangerous. I would be more than happy to discuss the why's over PM at your convenience. I come from a both civilian EMS and military combat medicine background, including a tour in Iraq. Unfortunately, burns are something we saw a lot of. The plus side of that is treatment/wound management is making leaps and bounds.

Just for everyones general knowledge fund:

Do NOT rupture blisters in the course of burn management. The fluid that collects in unruptured blisters is sterile, as is the skin environment the blister is covering. Damaging that to drain the blister destroys that protected environment and does nothing more than open another pathway of infection into your patient. And a patient in a wilderness settings with full- or partial-thickness burns has enough problems as is. Protect those blisters! If they are large, bandage them the same way you would a penetrating injury where the object is still there and sticking out.

But what about blisters that contain pus, as opposed to serum (a form of blood plasma)? At that point the wound is already infected, and again, the best course of action for the patient is rapid transport to medical care. Rupturing the blister to clean the pus and the blister site again just invites more and varied infection, especially in a wilderness setting.

Debridement: Don't do this in the field. Don't. Period. Debridement is meant to be done in a sterile environment, as you are opening up the wound in an attempt to clean it. Time spent in an amateur attempt to debride a would not only has the very real possibility of making it worse, but is also time that could be used getting the patient to professional medical care.

I'm also unfamiliar with "4th degree" burns. I've never heard that in going on 7 years of EMS. Also, recently, the terminology changed from 1st, 2nd, and 3rd degree to Superficial, Partial-thickness, and Full-thickness. Don't ask me why...I'm sure some council of doctors feels more important when they use more syllables.

Oh, and silver dressings, while they work, can actually increase heal time, and thusly may not be ideal outside of the clinical setting.

Keep in mind, this is advice I would give to people who have training and experience in emergency medicine. I'm not trying to bust anyones chops here, or lord over anyones lack of knowledge. Anyone with issues or questions can PM me at any time. Alan is absolutely right about burn management, of ANY kind, being tricky. Much more so in a wilderness setting.


Edit: I googled it, and apparently 4th degree burn is out there. However, I also hit up a couple of nurses, another medic, and my SOF Medical, Ranger Medic, and Combat Medic handbooks. No mention or familiarity with this term, and every definition to me sounds exactly like what I know to be full-thickness burns.

[chewy352]

Alan,

But what about blisters that contain pus, as opposed to serum (a form of blood plasma)?

How can a non professional tell the difference between a blister that contains pus and a blister that contains serum?

[Alan Halcon]

Adrenalinemedic, I agree 100% with your post. Folks he's on the money

That being said, the article was meant for those far away from help, which is why I stated the whole wilderness thing, and also stated this is a very tricky subject because of differing expertises. Many times, one may not have the luxury of medical attention. And, at least for a second degree burn, there still is a way to treat in the outdoors, or SHTF situation.

Blisters, indeed, are a breeding ground for bacteria, if ruptured. The problem with big blisters, through all the flexing and what not many times rupture on the their own, especially on big burns.

As for blisters containing pus, damn well there is another sticky. If no medical help is in site or within reach what do you do? what about a SHTF situation? Clearly, it is infected, so do we provide field care or not?

I assure you adrenalinemedic, I thought long and hard before I wrote this article. Burn management is tricky. I knew it was going to raise eyebrows. At the same time, however, It is something that needs to be addressed.

All that said, adrenalinemedic, I would like for the sake of our readers and my edification, if you wouldn't mind sharing with us how you would go about treating a second degree burn in the field and how you would manage infected, again provided emergency room is not available.

[adrenalinemedic]

How can a non professional tell the difference between a blister that contains pus and a blister that contains serum?

Serum is clear; its the stuff you see when you have a blister on your toe breaking in boots.

Pus is...well, pus. Usually a greenish/yellowish opaque fluid depending on the varitety.

[adrenalinemedic]

Sorry for the delay, I dont check CG too often.

degree burn, there still is a way to treat in the outdoors, or SHTF situation.

Blisters, indeed, are a breeding ground for bacteria, if ruptured. The problem with big blisters, through all the flexing and what not many times rupture on the their own, especially on big burns.

Very true. This is where improvisation comes in. But I'll get to that.

As for blisters containing pus, damn well there is another sticky. If no medical help is in site or within reach what do you do? what about a SHTF situation? Clearly, it is infected, so do we provide field care or not?

Absolutely. I just want to be clear, it wasn't treatment of (potential) infection I had a problem with, it was draining blisters/wound debridement.

All that said, adrenalinemedic, I would like for the sake of our readers and my edification, if you wouldn't mind sharing with us how you would go about treating a second degree burn in the field and how you would manage infected, again provided emergency room is not available.

Lets throw out some scenarios here. I hate to play the "What If" game, because if you've ever been around soldiers, you know it goes downhill quick. However, this isn't a one size fits all kind of topic.

You brought up a person falling into a campfire as an example of injury. Lets say that someone trips and falls face forward, sticks their hands out unconsciously to catch themselves, and ends up with severe superficial and partial-thickness burns on their palms and fingers.

Fingers are a horrendous place for burns, as the hands move a great deal, and often subconsciously (like when people talk or are nervous). The key here is to keep the fingers separate, because burned flesh with fuse to itself. If you wrap a bunch of gauze around some guys burned hands, he's going to end up with a flipper.

I started to try and type this out, but I'm no wordsmith, so I took some pictures. I used a small ace wrap I had because it was open; all of my curlix is sealed Sorry about the awkward angles and such; this is a dressing that is better accomplished with two hands, and I was taking pictures while trying to make it work.

Step one: Have the Pt spread their fingers as much as they are able. Start a loose wrap (LOOSE) around the wrist or palm.


Step two: Come around the pinky side of the hand, and start gently draping gauze between the fingers.


Step three: The goal is to make a series of "U"s of gauze draped between the fingers.


Step four: When you get to the inside of the hand, have the Pt close their fingers, trapping the double layer of gauze between them

[adrenalinemedic]

(Too many images for the first post, hence the split nature.)

Step five: Take the tail end of the gauze and come around the hand again LOOSELY, but tight enough you trap and fold the hanging "U"s of gauze.


Step six: Continue the rest of the wrap, and when you hit the end, either tuck or tape.


A closeup of the fingers, so you can see the material between each one:



Now if the fingertips are burned, you can take that running end (or a second wrap if you run out) and cover them as well. But the key here is to prevent burned flesh-on-flesh contact. Also, while you might choose to flush the wound immediately with cool water, you want to apply DRY, STERILE gauze. I don't advocate large scale application of topical antibiotic.

I'm actually going to have to come back to this topic with some other Tx options (large scale burns on arms/back, Pt movement, etc) because its 330am and insomnia only carries you so far. I should be able to this this again tomorrow night.

[Alan Halcon]

Good stuff! thanks.

Nice loose dressing.

Looking forward to the rest of this.

Alan