BURNS

1. Begin emergency care

1.1 If you are at the scene of an accident, you may need to remove the patient from harm or stop the burning process:

• If electrical burn, always turn the current off or use a stick to get the electircal wire away before you touch patient. be ready to do CPR! An electric shock can cause cardiac arrest.
• If chemical burn, have a helper immediately begin to flood the burn with water and continue for at least 15-30 minutes (see plan 5.1).
• If chemical is in eye, go to plan on p.99.
• If you see flames, smother them or spray them with water.
• If you see steaming, hot, wet clothing, have a helper pour on cool water.

1.2 Check ABC's as soon as possible: Airway, Breathing, Circulation.

1.3 Control severe bleeding.

1.4 Prevent shock:

• Patient should lie down.
• Keep patient warm.

1.5 Check vital signs: P, R, BP. If shock (weak, fast pulse; low BP), go to p.7.

• Use LACTATED RINGERS for I.V. fluid.
• Plan NOT to use I.V. fluid with DEXTROSE (in a burn patient, it may cause problems with blood cells).
• If severe burn, plan to have helper recheck vital signs at least every 15-30 minutes.

1.6 Give OXYGEN if needed (if patient breathed in smoke or is short of breath). Follow guidelines on p.435.

1.7 While you get history and examine, a helper could do the following:

First, treat serious injuries.

• Example: splint a broken bone.

Begin to cool burns caused by heat:

• For burns with no blisters (first degree), see plan 5.3.
• For other heat burns (second or third degree), see plan 5.4. 2.

2.1 History of Present Illness

Get general history of present illness (inside cover).

Also ask the following specific questions:

• Exactly what happened?
• What caused the burn?
• If fire caused it, did patient breathe in any smoke?
• Did it happen in an enclosed area?
• If a chemical burn, what was the chemical?
• battery acid?
• bathroom cleaner?
• gasoline?
• oven cleaner?
• Drano®?
• ammonia?

If needed, have a helper get the chemical's container.

You will need to report the name.

Some chemicals can be absorbed through the skin causing liver or kidney damage.

Was the accident related to alcohol or other drugs?

2. Where is the patient burned?

3. Does patient have any other injuries?

4. Does patient have any other complaints, such as: Severe pain?

Symptoms of shock:

feeling weak, tired?

Coughing?

If coughing up sputum, what does it look like?

black sputum means respiratory damage.

Shortness of breath?

Nausea or vomiting?

2.2 Past Health History

1. Illnesses?

2. What medicine(s) is the patient taking now?

3. Allergies?

4. When was last TETANUS shot?

3. Exam

3.1 Repeat vital signs: P, R, BP.

3.2 Do a body survey (p.9). Especially check:

• Mouth, nose, and throat for burns.
• Breath sounds.

3.3 Examine the burn.

Where exactly is the burn? Decide how deep the burn is: no blisters (first degree). blisters or deeper (second or third degree). if needed, use information on p.334.

If electrical burn, look for at least 2 burns: there will be a small entrance wound where the electricity entered the body.

there will be one or more wounds where the electricity left the body.

3.4 If the burn is large, decide what percent of the skin is burned.

Use the information on p.334.

4. Assessment

4.1 Your assessment should be: burn.

4.2 Include in your assessment that the burn is one of the following:

Chemical Burn (Plan 5.1).

Electrical burn (Plan 5.2).

Heat Burn:

Heat burn with no blisters (first degree) (Plan 5.3).

Other heat burn (second or third degree) (Plan 5.4).

5.1 Plan: Chemical burn

1. Flood with water immediately:

Use a gentle stream of plain water, so you do NOT injure skin more. Use a shower, faucet, or have a helper keep refilling water bottles as you irrigate.

Avoid more damage: patient should tilt his body so that the chemical and water will run off, not onto other parts of his body.

DO NOT get the chemical on you.

As soon as you have cared for patient, change your clothing if it has chemical on it.

If chemical is in eye, be sure to follow plan on p.99.

Continue flooding the skin while you or a helper: remove all clothing. remove jewelry (rings, bracelets) to prevent damage if hand swells.

2. Report NOW to your referral doctor.

Have a helper continue to flood the skin while you contact the doctor. If you can NOT reach a doctor: Follow this plan until you can.

If you think patient needs care at the hospital, have someone arrange for transport.

3. Continue to flood with water as follows: If you CANNOT reach the doctor, flood for at least 15-30 minutes after clothing if off.

Patient should state that the burning has stopped.

If the chemical is alkali such as lye, lime (plaster of paris), ammonia or Drano® (sodium hydroxide): flood for at least 30-60

minutes after clothing is off.

Try again to contact a doctor.

He may tell you to flood for a longer time.

4. Other Plan.

Treat the same as for heat burns: for minor burns with no blisters, go to plan 5.3.

Follow parts of plan which apply.

For more serious burns, treat the same as for second or third degree heat burns.

Now go to plan 5.4.

Follow parts of that plan which apply.

5.2 Plan: Electrical Burn

Burns caused by electricity can be severe, even though the skin may not look like it is hurt much.

Electricity does much damage to nerves and blood vessels along its path.

1. Report NOW to your referral doctor. If you CANNOT reach a doctor: Follow this plan until you can.

Arrange for transport to a hospital, unless the injury is

very minor.

Most patients with electrical burns need hospital care, possibly surgery.

Do not cool an electrical burn.

Otherwise, treat the same as for second or third-degree heat burns.

Now go to plan 5.4.

Follow parts of that plan which apply.

5.3 Plan: Heat Burn With No Blisters (First Degree)

1. Cool most burns soon after injury to reduce pain and tissue damage.

Do NOT cool if patient is cold or in shock. Do NOT cool large areas of the body (burns that involve more than 20% of skin).

This may cause hypothermia.

Use plain, cool water.

NEVER add ice to salt water (saline).

The water becomes too cold and can cause frostbite.

Place the burned part in cool water or apply cold, wet cloths. Cool for about 5 minutes.

While you are cooling, remove jewelry (rings, bracelets) to prevent damage if hand swells.

2. Report to your referral doctor unless he has signed for you to treat minor burns without contacting him.

Always report if the burn is large or seems severe.

While you are waiting to report, follow this plan.

3. Other plan may include the following:

If burn is on an arm or leg, patient should elevate it above the level of his heart to reduce swelling and pain.

If needed, for pain, give ASPIRIN or ACETAMINOPHEN (Tylenol®)(p.416).

Usually no other treatment is needed for a minor burn that does not form blisters.

You may decide to apply a thin layer of SILVER SULFADIAZINE (Silvadene®) or PETROLEUM JELLY (Vaseline®) if it feels better to the patient.

When the time is right, talk about burn/accident prevention.

If problem is related to alcohol or other drug abuse: remind

patient kindly of this.

Talk with patient about the alcohol or drug problem.

Follow the plan on p.204.

Recheck only if needed.

Tell patient to return to clinic if the burn is getting worse instead of better.

5.4 Plan: Other Heat Burn (Second or Third Degree)

1. Begin wound care as follows:

Remove jewelery (rings, bracelets) to prevent damage if hand swells.

Cut away burned clothing.

If an area of clothing is stuck to the skin, cut around it.

Try NOT to break blisters. Blisters help to prevent infection.

2. Cool most burns soon after injury to reduce pain and tissue damage.

Do NOT cool if patient is cold or in shock.

Do NOT cool large areas of the body (burns that involve more than 20% of skin).

This may cause hypothermia.

Use cool, plain water.

NEVER add ice to salt water (saline).

It reduces the melting point of the water and can cause frostbite.

Place the burned part in cool water; or wash hands well, put on sterile gloves and apply cool, wet gauze.

Cool for about 5 minutes.

3. Report to your referral doctor.

Report NOW :

Unless patient only has second degree burns (blisters) that are small: less than 10% of the skin.

Older child and young adult: under age 2 or over age 40: less than 5% of the skin.

If you CANNOT reach a doctor: Follow this plan until you can.

Have someone arrange to transport to hospital if burn is severe .

This includes the following:

Second degree burns (blisters) on the face, neck, hands, feet, or genitals ( these are small but important areas).

Second degree burn that goes all the way around an arm or leg (circumferential burn).

Large second degree burns in any area.

All third degree burns.

Signs of repiratory damage, such as shortness

of breath, hoarse voice, mouth burns or coughing black sputum. Burns along with a broken bone or other serious injury.

4. Apply a dressing as follows:

For most burns, apply a dry, sterile dressing and bandage.

In an emergency, use a clean, dry sheet.

DO NOT apply butter, shortening, or other grease.

If burns are near a joint (knuckle, armpit, elbow), protect the skin by

applying sterile 4x4's with SILVER SULFADIAZINE (Silvadene®) or another antibiotic/burn cream (as on p.439).

Be sure to place 4x4's between two burned areas that may touch. This will help to keep the skin from breaking down and growing together.

If a blister breaks: put on sterile gloves.

Use sterile forceps and scissors (boil for 20 minutes) to cut away loose skin.

Apply sterile 4x4's with SILVER SULFADIAZINE (Silvadene®) or another antibiotic/burn cream (as on p.439).

5. If burns are severe, your plan while waiting for transport should include the following:

Diet: noting by mouth.

Start an I.V. (p.427).

use LACTATED RINGERS I.V. fluid.

Plan NOT to use I.V. fluid with DEXTROSE ( in a burn patient, it may cause problems with the blood cells).

Run it at a "maintenance rate" (p.434), until your doctor tells you a different rate or the patient goes into shock.

If you CANNOT start an I.V. and/or transport is delayed, it may be possible to replace some fluid by mouth.

Patient must be awake and not vomiting.

Patient should drink small sips of clear liquids as often as possible. Give ORAL REHYDRATION SALTS or other clear liquids, the same as suggested for vomiting or diarrhea in a baby (p.74).

Recheck vital signs at least every15-30 minutes (P, R, BP).

Pain control: reassure patient.

If pain is severe, you CANNOT reach a doctor, and patient is NOT in shock, give an I.M. shot of MEPHERIDINE (Demerol®) or MORPHINE (p.417).

Cover burns well, to lessen air movement over burn.

If burn is on an arm or leg, elevate it above the level of the patient's heart.

If patient has NOT had a TETANUS booster shot in the past 10 years: Give I.M. Booster shot of TETANUS TOXOID and DIPTHERIA (Td)

Dose: 0.5cc I.M.

If patient has third degree burns, your referral doctor may suggest that you have an antibiotic:

I.M. shot of PROCAINE PENICILLIN (Wycillin®).

Plan to give shot every 24 hours:

weight approximate age dose:

less than 4 months less than 15 lbs. : 150,000 units

4-17 months 15-24 lbs. :300,000 units

18 months-3 years 25-34 lbs. : 450,000 units

4 years or more 35 lbs. or more : 600,000 units

OR, if allergic to PENICILLIN: ERYTHROMYCIN (200mg/5ml suspension or 250mg tablets) four times a day

Weight Approximate age dose

less than 15 lbs less than 4 months: 60mg (1.5 cc)

15-24 lbs 4-17 months: 80mg (2cc)

25-34 lbs. 18 months-3 years: 140mg (3.5 cc)

35 lbs or more 4 years or more: 200mg (5cc)

50-89 lbs 7-11 years 250mg (1 tablet)

90 lbs or more 12 years or more 500mg (2 tablets)

6. If burns are NOT severe, your plan should include the following:

Pain control: reassure patient. If needed, give ASPIRIN OR

ACETAMINOPHEN (Tylenol®) (p.416).

Tell patient to cover burns well in order to lessen air movement over burn.

If burn is on an arm or leg, patient should elevate it above the level of his heart.

Other patient education:

rest the injured part.

keep the burn dry.

do NOT break blisters.

If patient has NOT had a TETANUS booster shot in the past 10 years: Give I.M. booster shot of TETANUS TOXOID and DIPTHERIA (Td)

Dose: 0.5cc I.M.

7. Recheck as follows:

Recheck at these times:

In one day, sooner if dressings become wet from burn drainage.

Once a day until burn is healed.

Examine: temperature. burn.

For all second and third degree burns, apply a dressing of sterile 4x4's with SILVER SULFADIAZINE (Silvadene) or other antibiotic/burn cream (as on p.439) one day after the accident. Dressings should be changed twice a day, more frequently if they become wet from burn drainage.

You should do one of these dressing changes.

Teach patient or family member how to do the other changes at home.

If burn is getting infected (fever; getting more tender, warm, red, swollen or pus seen), treat as on p.321, "Infected Wound".

When the time is right, talk about burn/accident prevention.

If problem is related to alcohol or other drug abuse: remind patient kindly of this.

Talk with patient about the alcohol or drug problem.

Follow the plan on p.204.

Burns: General Information Most burns are caused by heat, chemicals, or electricity.

The important things you should examine and report about a burn are:

How deep it is (thickness, degree).

The place on the body that is burned.

The percent (amount) of skin that is burned.

Deciding How Deep a Burn Is (Degree of a Burn)

Use the following information to help you decide:

First degree burn:

This burn is not very deep.

It only makes the skin red.

It usually hurts but is not very serious.

It heals in 4-7 days.

The top layer of skin may peel as it heals.

example: mild sunburn.

Second degree burn (partial thickness):

This burn goes deeper into the skin than the first degree burn.

Often it is caused by hot liquids.

It causes blisters.

It usually hurts much more than a first degree burn.

It heals in 2-3 weeks, unless it gets infected.

Third degree burn (full thickness):

This burn is deeper than the other two.

The burn goes through the full thickness of the skin.

It may even go deeper, into muscle and bone.

The skin may look charred or cooked.

The burn may be black, brown, white, gray, or red.

The center of the burn does NOT hurt, because the nerves in the skin have been killed.

You can pull hairs out if the skin without causing any pain.

The edges of the burn may be very painful, however.

It heals very slowly or needs skin grafting (surgery).

Mixed degrees of burns:

Serious burns often have a mixture of the above.

For example, patient may have second and first degree burns around a thrird-degree burn.

Deciding What percent of the skin is burned

1. Make a drawing on your SOAP note:

Draw an outline of the patient's body.

Shade where the burns are.

This will help you to report:

exactly where the burns are.

how much of the body is burned.

2. For large burns, use the drawings that follow for an adult or infant.

Add up the percent of skin burned in different places on the body. *visual stimulation: Front. Back. Burn area, adult: rule of 9's.

*more visual stimulation: front. back. burn area, infant.

For smaller burns, you can use patient's palm size to decide the size of burn.

The palm = about 1% of the

skin.