Burns and Environmental Emergencies: Complete Care and Treatment Guide

OBJECTIVES

Upon completion of this lesson, you will be able to:

1. Define burn and describe the causes of burn.
2. Match the signs and symptoms for each of the three types of burns according to their depth.
3. Apply the “Rule of Nines” to determine the Total Body Surface Area (TBSA) burnt on a patient when given a specific part of the body.
4. List three steps for pre-hospital treatment of chemical burns.
5. List three steps for pre-hospital treatment of electrical burns.
6. List three signs and symptoms of heat cramps, heat exhaustion, and heat stroke and describe pre-hospital treatment for each.
7. List three signs and symptoms of both mild and severe hypothermia and list six steps for pre-hospital treatment.
8. List three signs and symptoms of frostbite and three steps for pre-hospital treatment.

1. Burns

Definition:
Injuries caused by exposure to excessive heat from thermal, chemical, electrical, or radiating sources.

1.1 Causes

• Thermal: Heat (fire, vapor, and hot objects) and very cold (freezing or frozen objects).
• Chemical: Includes several caustics such as acids and alkalis.
• Electrical: Electricity, such as house current or lighting.
• Radiant: Ultraviolet rays (including sunlight) and radioactive agents.

1.2 Classification, Signs, and Symptoms

Classification by depth:

• Superficial (first-degree) burns:
  These involve only the top layer of the skin.

• Partial thickness (second-degree) burns:
  The superficial layer of the skin is burned through, and the second layer is damaged.
  
• Full thickness (third-degree) burns:
  All layers of the skin are burnt, including the fatty layer.
  

The Rule of Nines for Adults and Children

Extent of Burns

Body Part	Adult (%)	Child (%)
Head	9%	18%
Upper extremities	9% each	9% each
Anterior Trunk	18%	18%
Posterior Trunk	18%	18%
Genital	1%	Included in anterior trunk
Lower Extremities	18% each	14% each

BSA (Body Surface Area)

100% (for both Adults and Children)

The bottom part of the image shows diagrams of an adult and child, with labeled percentages indicating the extent of burns for different body areas.

• Adult:
  • Head: 4.5% front, 4.5% back
  • Arm: 4.5% front, 4.5% back (each arm)
  • Leg: 9% front, 9% back (each leg)
  • Anterior and Posterior Trunk: 18% each
• Child:
  • Head: 9% front, 9% back
  • Arm: 4.5% front, 4.5% back (each arm)
  • Leg: 7% front, 7% back (each leg)

1.3 Burn Severity

The two primary factors considered in rating burn severity are body surface area (BSA) and location. Burn severity can be rated as follows:

Minor Burns

• Full-thickness burns of less than 2% BSA, excluding face, hands, feet, genitalia, or respiratory tract.
• Partial-thickness burns of less than 15% BSA.
• Superficial burns of 50% BSA or less.

Moderate Burns

• Full-thickness burns of 2% to 10% BSA, excluding face, hands, feet, genitalia, or respiratory tract.
• Partial-thickness burns of 15% to 30% BSA.
• Superficial burns over 50% BSA.

Critical Burns

• All burns complicated by injuries of the respiratory tract, other soft-tissue injuries, and injuries of the bones.
• Partial- or full-thickness burns involving the face, hands, feet, genitalia, or respiratory tract.
• Full-thickness burns of more than 10% BSA.
• Partial-thickness burns of more than 30% BSA.
• Burns complicated by musculoskeletal injuries.
• Circumferential burns.

Additional Considerations:

• Source of the burn:
  • Electrical burns:
  • Chemical burns:
• Body regions burned:
  • Face:
  • Hands and feet:
  • Groin, genitalia, buttocks, and inner thighs:
  • Burns around joints:
• Other complicating factors:

NOTE:
Burns which by the above classification are moderate should be considered critical in a patient less than 5 or more than 55 years of age.

1.4 Pre-hospital Treatment for Burns

Use universal precautions and secure the scene.

1. Stop the burning process. Run cold water over the scald burns. Flush away chemicals with water for _____ minutes or more.
2. Remove any smouldering clothing and jewellery. If you meet resistance or if you see pieces melted into the skin, cut around the area. Do not try to remove them.
3. Perform initial assessment.
4. Administer oxygen per local protocol. Provide ventilation if needed.
5. Determine the severity of burns, using the rule of nines.
6. Cover the burns. Use dry sterile dressings or disposable sterile burn sheet. Do not use grease or fat, ointment, lotion, antiseptic, or ice on the burns. Do not break any blisters. If a burn involves the eye, be sure to cover both eyes after treating. Fingers with second- or third-degree burns require dressing each finger individually.
7. Keep the patient warm and treat for shock.

1.5 Pre-hospital Treatment for Chemical Burns

Use universal precautions, secure the scene, and alert EMS.

CAUTION: If the patient is contaminated, wash off the person from a distance to avoid exposing yourself to the chemicals.

1. Brush off dry chemicals, such as lime powder, before flushing with water.
2. Rinse the area with water for at least 20 minutes or more. Remove and set aside clothes and jewellery while the patient is being washed off.

1.6 Pre-hospital Treatment for Chemical Burns to the Eyes

Rinse the eyes immediately with water for at least 20 minutes. Maintain a flow of water on the affected eye from a faucet (low pressure), bottle, glass, or other source. Keep the patient’s eyelid(s) open.

1.7 Pre-hospital Treatment for Electrical Burns

The more serious problems related to electrical burns are respiratory and/or cardiac arrest, damage to the nervous system, and injury to internal organs. Follow local protocols. Use universal precautions, secure the scene, and alert EMS.

Prolonged CPR should be performed on electrical injury victims as they can remain viable for a longer period than with other types of injuries.

Care for electrical burns the same as any other type of burn, also using the following specific guidelines for electrical burns:

1. Perform initial assessment.
2. Evaluate burns and look for at least two burn areas:

1.8 Inhalation Injury

This type of injury occurs when a patient inhales heated air, smoke, and/or toxic products. Symptoms for these injuries may appear mild initially, then become more severe.

Signs and Symptoms of Inhalation Injury

• Coughing and wheezing.
• Hoarseness or difficulty speaking.
• Singed nasal hairs or soot around the nose and mouth.
• Difficulty breathing or shortness of breath.
• Black or carbon-stained sputum.

Pre-hospital Treatment for Inhalation Injury

1. Administer oxygen per local protocol.
2. Monitor patient’s airway and breathing.
3. Be prepared to ventilate.

2. Environmental Emergencies

2.1 Heat Exposure

Exposure to excessive heat can produce serious health conditions. There are three common emergencies brought about by exposure to excessive heat:

• Heat cramps
• Heat exhaustion
• Heat stroke

Heat Cramps

Heat cramps consist of pains and muscle spasms that occur when the body loses a large quantity of salt and electrolytes through excessive sweating.

Signs and Symptoms of Heat Cramps

• Painful muscle spasms, often in the legs or abdomen.
• Excessive sweating during physical activity.
• Fatigue or weakness.
• Mild dehydration or thirst.

Pre-hospital Treatment for Heat Cramps

1. Move the patient to a cool area.
2. Give the patient water. The muscle cramp should be alleviated after drinking water.The patient needs the water more than the salt – do not delay giving water to look for salt.
   Commercial electrolytes or oral rehydration solution.

Heat Exhaustion

Heat exhaustion can occur when a person in poor physical condition exerts himself or herself during physical activity in a very hot environment, causing blood flow to be affected.

Signs and symptoms of heat exhaustion

• Profuse sweating.
• Pale, cool, and clammy skin.
• Weakness or fatigue.
• Dizziness or fainting.
• Nausea or vomiting.

Pre-hospital treatment for heat exhaustion

1. Move the patient to a cool place to rest.
2. Remove or loosen clothing as necessary to cool the patient without causing chills.
3. Place the patient in a supine position with legs elevated 20 to 30 cm.
4. Administer oxygen per local protocol.
5. Give water, but not to an unconscious patient.

Heat Stroke

Heat stroke is a very serious life-threatening condition. The body becomes overheated and, in many cases, the patient stops sweating. If left untreated, brain cells will begin to die.

Signs and symptoms

• Hot, dry, and red skin (no sweating).
• Rapid, strong pulse.
• Confusion, altered mental state, or unconsciousness.
• Rapid breathing or hyperventilation.
• Headache, dizziness, or nausea.

Pre-hospital treatment for heat stroke

Use universal precautions, secure the safety, and alert EMS.

1. Cool the patient quickly in any way possible. Move the patient away from the source of heat. Remove his or her garments and wrap the patient with wet sheets. Pour cold water on the sheets. This should normalize the patient’s core temperature and help prevent brain cells from dying.
2. Place cold bags or ice packs below each armpit, behind the knees, around the ankles, and one on each side of the neck.
3. Look for a large container or bathtub and submerge the patient in cold water up to the neck.
   Use ice to cool the water.

Heat Emergency Comparison Chart

	Heat Cramps	Heat Exhaustion	Heat Stroke
Muscle cramps	Yes	No	No
Sickness	Yes	Yes	Yes
Breathing	Varies	Quick & Superficial	Deep initially, later superficial
Pulse	Varies	Weak	Pulse Rapid & Strong
Skin	No change	Cool clammy and pale	Dry red and hot
Loss of consciousness	Rarely	Sometimes	Frequently

2.2 Cold Emergencies

Exposure to excessive cold can cause two kinds of emergencies:

• Hypothermia
• Frostbite or local cold injuries

Hypothermia

When cooling affects the entire body, this causes a condition known as hypothermia, or generalized cooling. Hypothermia can develop in temperatures well above freezing.

Signs and symptoms of mild hypothermia

• Shivering or trembling.
• Cold, pale, or blue-tinged skin.
• Fatigue or drowsiness.
• Confusion or impaired judgment.
• Slurred speech or slowed reactions.

Signs and symptoms of severe hypothermia

• Absence of shivering (indicating the body’s inability to generate heat).
• Extremely cold, pale, or bluish skin.
• Weak or irregular pulse.
• Slow, shallow, or irregular breathing.
• Loss of coordination, including inability to walk or grip objects.
• Unconsciousness or unresponsiveness, potentially leading to cardiac arrest

Pre-hospital treatment for hypothermia

Handle patient very gently and offer comfort and reassurance. Use universal precautions, secure the scene, and alert EMS.

1. Conduct initial assessment and physical exam.
   • Check for responsiveness and signs of life.
2. Remove the patient from the cold environment.
   • Place the patient in a warm, sheltered area.
3. Maintain open airway and administer oxygen per local protocol.
   • Provide warm, humidified oxygen if available.
4. Remove any wet clothing and cover the patient with a blanket. Keep the patient dry.
   • Insulate the patient from cold surfaces using blankets or padding.
5. If the patient is alert, offer warm liquids (non-stimulant) slowly.
   • Avoid alcohol or caffeine, as they can worsen heat loss.
6. Constantly assess vital signs.
   • Monitor for signs of worsening hypothermia, such as decreased pulse or respiration.

Frostbite or Local Cold Injuries

This type of injury consists of the freezing or near-freezing of a body part. Usually the toes, fingers, face, nose, and ears are at most risk. Onset is slow but can occur quickly under high wind conditions.

Signs and symptoms of frostbite and local cold injuries

• Skin that appears pale, white, or waxy and feels cold or numb.
• Tingling or burning sensation in the affected area, followed by a loss of feeling.
• Hard or frozen skin, with underlying tissue feeling firm to the touch

Never rub or massage the affected area of a local cold injury. Ice crystals under the skin could damage the fragile capillaries and tissues, making the injury worse.

Pre-hospital treatment for frostbite and local cold injuries

If you suspect hypothermia, treat for hypothermia before treating for frostbite (“life before limb“). Use universal precautions, secure the scene and alert EMS.

1. Remove the patient from the cold environment. Do not allow the patient to walk on a frozen limb.
   • Keep the affected area elevated to reduce swelling.
2. Protect the frozen area from further injury and re-freezing. For an injured extremity, stabilize.
   • Avoid rubbing or massaging the area, as this can cause further damage.
3. Dry the affected area and apply a clean bandage. Place dressings between the fingers if they are affected. If superficial, cover and keep warm. If deep, apply dry, sterile dressings.
   • Avoid direct heat sources, such as heaters or fires, to prevent burns.
4. If transport will be delayed, consider re-warming the affected area. Follow local protocols.
   • Use lukewarm water (not hot) for re-warming if advised by medical personnel.

Late or Deep-cold Injury

Later stages of frostbite are referred to as late or deep-cold injury. In this condition, the skin may appear to be waxy and may be firm to the touch. As freezing continues, it becomes mottled and blotchy. Finally, the area becomes swollen, blistered, and white. This type of injury can appear similar to partial thickness (second-degree) burns.

• Tissue may become blackened in severe cases, indicating necrosis.

Signs and symptoms of late or deep-cold injury

Signs and symptoms of late or deep-cold injury

• Blotches in the skin (spotted). White colour appears first, then greyish yellow, and finally greyish blue.
• Swelling and formation of blisters, which may contain clear or bloody fluid.
• The surface of the skin will feel frozen in the affected area, and the layers of skin below the surface will feel hard to the touch.
• Severe pain upon rewarming of the affected area.

Pre-hospital treatment for late or deep-cold injury

Use universal precautions, secure the scene, and alert EMS. Provide the same treatment as for frostbite.
• Do not attempt to rewarm the area unless re-freezing can be prevented.
• Gently wrap the area with dry, sterile dressings, avoiding tight bandages.
• Elevate the affected area to reduce swelling.

Never rub or massage an area with deep-cold injury.
• This can cause further tissue damage and worsen the injury.

 

Conclusion

In conclusion, understanding the intricacies of burn injuries and environmental emergencies is crucial for providing effective pre-hospital care and potentially saving lives. Burns can range from superficial to critical, with severity determined by factors such as depth, location, and total body surface area affected. Each type of burn—thermal, chemical, electrical, and radiation—requires specific approaches to treatment, including the prompt application of the “Rule of Nines” for TBSA calculation and the use of sterile dressings to prevent infection. Similarly, emergencies caused by extreme heat or cold demand rapid intervention. Recognizing and treating conditions such as heat cramps, heat exhaustion, heat stroke, hypothermia, and frostbite can prevent further complications or permanent damage.

Adhering to universal precautions and securing the scene are paramount in all situations to ensure safety for both the rescuer and the patient. Whether cooling a burn, rehydrating a heat stroke victim, or gently warming a hypothermic patient, every action must be deliberate and informed by established protocols. As first responders or caregivers, preparedness and knowledge make the difference in delivering timely and effective care. By applying these principles and treatments, we contribute to better patient outcomes and exemplify the importance of comprehensive emergency care training